Provider Demographics
NPI:1063294320
Name:PRUITT, TYLER RAY
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:RAY
Last Name:PRUITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76804-0936
Mailing Address - Country:US
Mailing Address - Phone:432-559-0978
Mailing Address - Fax:
Practice Address - Street 1:1803B AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-3656
Practice Address - Country:US
Practice Address - Phone:432-559-0978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82808101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional