Provider Demographics
NPI:1184283525
Name:PRUETT, JOHN (BCBA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:PRUETT
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 FULLERTON RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-2836
Mailing Address - Country:US
Mailing Address - Phone:703-463-7174
Mailing Address - Fax:781-437-1200
Practice Address - Street 1:7420 FULLERTON RD STE 104
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22153-2836
Practice Address - Country:US
Practice Address - Phone:703-463-7174
Practice Address - Fax:781-437-1200
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MA3108103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019866200Medicaid