Provider Demographics
NPI:1609112747
Name:PRUITT, LAURA CATHERINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:CATHERINE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 ASTER DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8190
Mailing Address - Country:US
Mailing Address - Phone:214-883-5148
Mailing Address - Fax:
Practice Address - Street 1:3833 S TEXAS AVE
Practice Address - Street 2:SUITE 217
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-4039
Practice Address - Country:US
Practice Address - Phone:979-846-5626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X
IA075061103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist