Provider Demographics
NPI:1770065609
Name:PRUITT, KASSANDRA SPARKS (COTA)
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:SPARKS
Last Name:PRUITT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4362 US HIGHWAY 259 N STE D
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7674
Mailing Address - Country:US
Mailing Address - Phone:903-212-7716
Mailing Address - Fax:
Practice Address - Street 1:4362 US HIGHWAY 259 N STE D
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7674
Practice Address - Country:US
Practice Address - Phone:903-212-7716
Practice Address - Fax:903-663-4833
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209629225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics