Provider Demographics
NPI:1841694981
Name:PRUITT, SAMANTHA (CADC II, ICADC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:CADC II, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 RICHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-4562
Mailing Address - Country:US
Mailing Address - Phone:209-525-7466
Mailing Address - Fax:
Practice Address - Street 1:2000 W BRIGGSMORE AVE
Practice Address - Street 2:STE. I
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3839
Practice Address - Country:US
Practice Address - Phone:209-526-1440
Practice Address - Fax:209-550-4903
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAA051060319101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)