Provider Demographics
NPI:1063958593
Name:PRUETT, LAURA STAR (MT-BC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:STAR
Last Name:PRUETT
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4424 E BASELINE RD APT 2255
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-7452
Mailing Address - Country:US
Mailing Address - Phone:832-289-9150
Mailing Address - Fax:
Practice Address - Street 1:4424 E BASELINE RD APT 2255
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-7452
Practice Address - Country:US
Practice Address - Phone:832-289-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-08
Last Update Date:2017-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist