Provider Demographics
NPI:1255814851
Name:PRUITT, REVONDA KISER (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:REVONDA
Middle Name:KISER
Last Name:PRUITT
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11310 US HIGHWAY 278 E
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:AL
Mailing Address - Zip Code:36272-8365
Mailing Address - Country:US
Mailing Address - Phone:256-310-9352
Mailing Address - Fax:
Practice Address - Street 1:502 W HOOD ST
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:AL
Practice Address - Zip Code:36272-1530
Practice Address - Country:US
Practice Address - Phone:256-447-9481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1685235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty