Provider Demographics
NPI:1558006353
Name:PRUITT, STEPHAN MICHAEL (LPC)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:MICHAEL
Last Name:PRUITT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 PARK PLACE DR APT 409
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-8958
Mailing Address - Country:US
Mailing Address - Phone:215-292-3425
Mailing Address - Fax:
Practice Address - Street 1:1258 BROWNSWITCH RD STE C
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-1606
Practice Address - Country:US
Practice Address - Phone:215-292-3425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7895101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional