Provider Demographics
NPI:1801555149
Name:PRUITT, ASHLY (LGPC)
Entity type:Individual
Prefix:
First Name:ASHLY
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5970 FREDERICK CROSSING LN STE 100
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-5176
Mailing Address - Country:US
Mailing Address - Phone:248-436-4400
Mailing Address - Fax:
Practice Address - Street 1:5970 FREDERICK CROSSING LN STE 100
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-5176
Practice Address - Country:US
Practice Address - Phone:240-415-8893
Practice Address - Fax:240-466-1993
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP12786101YM0800X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician