Provider Demographics
NPI:1497184287
Name:PRUETT, PHILIP
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:PRUETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4770 TOPAZ ST UNIT 84
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5509
Mailing Address - Country:US
Mailing Address - Phone:702-672-4789
Mailing Address - Fax:
Practice Address - Street 1:4770 TOPAZ ST
Practice Address - Street 2:84
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5508
Practice Address - Country:US
Practice Address - Phone:702-672-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor