Provider Demographics
NPI:1710350145
Name:PRUITT, ROSHAWON LATICE (AA, DSP I)
Entity Type:Individual
Prefix:
First Name:ROSHAWON
Middle Name:LATICE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:AA, DSP I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 CEDAR AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-4262
Mailing Address - Country:US
Mailing Address - Phone:562-606-4314
Mailing Address - Fax:
Practice Address - Street 1:735 CEDAR AVE APT 1
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-4262
Practice Address - Country:US
Practice Address - Phone:562-606-4314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-06
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No174400000XOther Service ProvidersSpecialist