Provider Demographics
NPI:1548743321
Name:PRUITT-KISER, ROXANNE (LCSW, LICSW)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:PRUITT-KISER
Suffix:
Gender:F
Credentials:LCSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLDG 4060 602ND ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703
Mailing Address - Country:US
Mailing Address - Phone:907-361-0229
Mailing Address - Fax:
Practice Address - Street 1:4060 602ND ST
Practice Address - Street 2:BACH
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703
Practice Address - Country:US
Practice Address - Phone:073-617-2039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0116761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN32055OtherLICSW
NCC011676OtherLCSW