Provider Demographics
NPI:1518542257
Name:PRUITT, MADISON ELIZABETH (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ELIZABETH
Last Name:PRUITT
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-7670
Mailing Address - Country:US
Mailing Address - Phone:302-584-4740
Mailing Address - Fax:
Practice Address - Street 1:52 9TH AVE
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-7670
Practice Address - Country:US
Practice Address - Phone:302-584-4740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7268235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZCS62210900Medicaid