Provider Demographics
NPI:1811195845
Name:PRUITT, HEATHER (PTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5513 CHAMBLEE DUNWOODY RD
Mailing Address - Street 2:SUITE 430
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-4106
Mailing Address - Country:US
Mailing Address - Phone:770-551-9633
Mailing Address - Fax:770-698-9184
Practice Address - Street 1:5513 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:SUITE 430
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-4106
Practice Address - Country:US
Practice Address - Phone:770-551-9633
Practice Address - Fax:770-698-9184
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002063225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant