Provider Demographics
NPI:1245888544
Name:PRUITT, LASHANTI MELBA (MA)
Entity type:Individual
Prefix:
First Name:LASHANTI
Middle Name:MELBA
Last Name:PRUITT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 WALTON WAY SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-3857
Mailing Address - Country:US
Mailing Address - Phone:404-844-3139
Mailing Address - Fax:
Practice Address - Street 1:995 ROSWELL ST NE STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2186
Practice Address - Country:US
Practice Address - Phone:404-844-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA832384688Medicaid