Provider Demographics
NPI:1710272331
Name:PRUITT, CARLA HOBBS (MED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:HOBBS
Last Name:PRUITT
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BUTTERCUP LN
Mailing Address - Street 2:
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-1622
Mailing Address - Country:US
Mailing Address - Phone:706-247-4277
Mailing Address - Fax:800-915-0219
Practice Address - Street 1:130 BUTTERCUP LN
Practice Address - Street 2:
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-1622
Practice Address - Country:US
Practice Address - Phone:706-247-4277
Practice Address - Fax:800-915-0219
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004360235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003110429EMedicaid