Provider Demographics
NPI:1700057288
Name:PRUITT, WAYNE NORMAN (DMIN)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:NORMAN
Last Name:PRUITT
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 WOLCOTT RD
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-3108
Mailing Address - Country:US
Mailing Address - Phone:617-566-3254
Mailing Address - Fax:
Practice Address - Street 1:93 WOLCOTT RD
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-3108
Practice Address - Country:US
Practice Address - Phone:617-566-3254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMH 1030-MF106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist