Provider Demographics
NPI:1336615418
Name:PRUITT, WYVETTA SMITH
Entity Type:Individual
Prefix:
First Name:WYVETTA
Middle Name:SMITH
Last Name:PRUITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 N 31ST ST STE D
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3900
Mailing Address - Country:US
Mailing Address - Phone:318-855-3868
Mailing Address - Fax:318-537-9688
Practice Address - Street 1:806 N 31ST ST STE D
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3900
Practice Address - Country:US
Practice Address - Phone:318-855-3868
Practice Address - Fax:318-537-9688
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5563104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker