Provider Demographics
NPI:1619112901
Name:PRUITT, MARY LOUISE (CADC II,ICADC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:CADC II,ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 ETHAN WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2225
Mailing Address - Country:US
Mailing Address - Phone:916-922-9217
Mailing Address - Fax:
Practice Address - Street 1:1440 ETHAN WAY STE 101
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2225
Practice Address - Country:US
Practice Address - Phone:916-922-9217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-16
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA03043920101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)