Provider Demographics
NPI:1982678520
Name:PRUETT, MIA (PHD)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:PRUETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-1443
Mailing Address - Country:US
Mailing Address - Phone:508-230-5083
Mailing Address - Fax:508-230-5089
Practice Address - Street 1:66 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1443
Practice Address - Country:US
Practice Address - Phone:508-230-5083
Practice Address - Fax:508-230-5089
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2491103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling