Provider Demographics
NPI:1609957158
Name:PRUITT, JOSEPH HENRY JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:HENRY
Last Name:PRUITT
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7250 FRANKLIN AVE
Mailing Address - Street 2:UNIT 1115
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-3049
Mailing Address - Country:US
Mailing Address - Phone:323-874-6966
Mailing Address - Fax:323-874-1419
Practice Address - Street 1:7250 FRANKLIN AVE
Practice Address - Street 2:UNIT 1115
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-3049
Practice Address - Country:US
Practice Address - Phone:323-874-6966
Practice Address - Fax:323-874-1419
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31479482103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL40890Medicaid
CA00PL40890Medicaid
CAR25488Medicare UPIN