Provider Demographics
NPI:1457154510
Name:PRUITT, BRENT
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:PRUITT
Suffix:
Gender:
Credentials:
Other - Prefix:MR
Other - First Name:BRENT
Other - Middle Name:ALONZO
Other - Last Name:PRUITT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:220 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75603-6667
Mailing Address - Country:US
Mailing Address - Phone:903-746-8389
Mailing Address - Fax:
Practice Address - Street 1:100 W HAWKINS PKWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-1816
Practice Address - Country:US
Practice Address - Phone:903-746-8389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty