Provider Demographics
NPI:1598458671
Name:PRUDEN, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:PRUDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HIGHLANDS BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2320
Mailing Address - Country:US
Mailing Address - Phone:631-331-8200
Mailing Address - Fax:
Practice Address - Street 1:100 HIGHLANDS BLVD
Practice Address - Street 2:STE 101
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2320
Practice Address - Country:US
Practice Address - Phone:631-331-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker