Provider Demographics
NPI:1740858943
Name:PRUITT, VANESSA (PLMHP)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 S EMPORIA ST APT 1416
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67216-4730
Mailing Address - Country:US
Mailing Address - Phone:402-984-5467
Mailing Address - Fax:
Practice Address - Street 1:312 N ELM ST STE 112
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-4509
Practice Address - Country:US
Practice Address - Phone:308-210-8487
Practice Address - Fax:844-270-3685
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12640101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health