Provider Demographics
NPI:1801872445
Name:PRUETT, JAMES WILLIAM (PHD; DMIN)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WILLIAM
Last Name:PRUETT
Suffix:
Gender:M
Credentials:PHD; DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 W HEATHERSTONE LN
Mailing Address - Street 2:
Mailing Address - City:ROEBUCK
Mailing Address - State:SC
Mailing Address - Zip Code:29376-2787
Mailing Address - Country:US
Mailing Address - Phone:704-577-5862
Mailing Address - Fax:864-574-8142
Practice Address - Street 1:3900-B PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209
Practice Address - Country:US
Practice Address - Phone:704-577-5862
Practice Address - Fax:864-574-8142
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC41101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCF156Medicare PIN