Provider Demographics
NPI:1508517608
Name:PRUITT, NAYESHA ADIA (LPC)
Entity Type:Individual
Prefix:MRS
First Name:NAYESHA
Middle Name:ADIA
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6224 S DORCHESTER AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-5184
Mailing Address - Country:US
Mailing Address - Phone:312-859-3675
Mailing Address - Fax:
Practice Address - Street 1:2659 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2851
Practice Address - Country:US
Practice Address - Phone:312-859-3675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.016203101YP2500X
IL2355616101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional