Provider Demographics
NPI:1710355722
Name:PRUITT, ALEXANDRIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDRIA
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 LILY CREEK RD STE 201
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2815
Mailing Address - Country:US
Mailing Address - Phone:502-338-0608
Mailing Address - Fax:502-246-1888
Practice Address - Street 1:912 LILY CREEK RD
Practice Address - Street 2:SUITE 201
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243
Practice Address - Country:US
Practice Address - Phone:502-429-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY170916103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical