Provider Demographics
NPI:1669861076
Name:PRUETT, MELISSA (LMFT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PRUETT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 ODANA RD
Mailing Address - Street 2:SUITE 20
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1170
Mailing Address - Country:US
Mailing Address - Phone:608-270-2511
Mailing Address - Fax:608-270-0467
Practice Address - Street 1:6333 ODANA RD
Practice Address - Street 2:SUITE 20
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1170
Practice Address - Country:US
Practice Address - Phone:608-270-2511
Practice Address - Fax:608-270-0467
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1106 - 124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherTAX ID