Provider Demographics
NPI:1417329020
Name:PRUITT, KALEEN J (LMT)
Entity Type:Individual
Prefix:
First Name:KALEEN
Middle Name:J
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 DANIELS ST UNIT 61277
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98666-0705
Mailing Address - Country:US
Mailing Address - Phone:360-207-1781
Mailing Address - Fax:
Practice Address - Street 1:9901 NE 7TH AVE # B223F
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-4523
Practice Address - Country:US
Practice Address - Phone:360-207-1781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60584715225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist