Provider Demographics
NPI:1457455875
Name:PRUITT, PAULINE C (LCSW)
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:C
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1568
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-6568
Mailing Address - Country:US
Mailing Address - Phone:540-825-3100
Mailing Address - Fax:540-825-6245
Practice Address - Street 1:650 LAUREL ST
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-3910
Practice Address - Country:US
Practice Address - Phone:540-825-5656
Practice Address - Fax:540-825-1612
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040032711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4945361Medicaid
VAS34144Medicare UPIN
VA4945361Medicaid