Provider Demographics
NPI:1205988532
Name:PRUITT, ANDRE B (PHD, MSW)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:B
Last Name:PRUITT
Suffix:
Gender:M
Credentials:PHD, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6926 NE 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-5245
Mailing Address - Country:US
Mailing Address - Phone:503-860-1213
Mailing Address - Fax:844-889-4937
Practice Address - Street 1:1220 SW MORRISON ST STE 730
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2226
Practice Address - Country:US
Practice Address - Phone:503-860-1213
Practice Address - Fax:503-988-3676
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR35291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORQ27063Medicare UPIN