Provider Demographics
NPI:1508347402
Name:PRUETT, LAURA F
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:F
Last Name:PRUETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 SITTERLY RD
Mailing Address - Street 2:
Mailing Address - City:HALFMOON
Mailing Address - State:NY
Mailing Address - Zip Code:12065-5613
Mailing Address - Country:US
Mailing Address - Phone:518-899-9235
Mailing Address - Fax:
Practice Address - Street 1:23 SITTERLY RD
Practice Address - Street 2:
Practice Address - City:HALFMOON
Practice Address - State:NY
Practice Address - Zip Code:12065-5613
Practice Address - Country:US
Practice Address - Phone:518-899-9235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY106S00000XOtherNEWMEADOW, INC