Provider Demographics
NPI:1578019204
Name:PRUITT, MIGNON
Entity Type:Individual
Prefix:
First Name:MIGNON
Middle Name:
Last Name:PRUITT
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 1:17125 BERNADINE STREET
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-1473
Mailing Address - Country:US
Mailing Address - Phone:773-671-1389
Mailing Address - Fax:
Practice Address - Street 1:741 EAST 75TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-1928
Practice Address - Country:US
Practice Address - Phone:773-891-3242
Practice Address - Fax:312-874-7219
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490061361041C0700X, 101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1326447020OtherGROUP NPI