Provider Demographics
NPI:1093532384
Name:PRUIETT, MICAELA ELIZABETH (LPC)
Entity type:Individual
Prefix:MRS
First Name:MICAELA
Middle Name:ELIZABETH
Last Name:PRUIETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MISS
Other - First Name:MICAELA
Other - Middle Name:ELIZABETH
Other - Last Name:PRUIETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:116 W PAWNEE AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67213-4815
Mailing Address - Country:US
Mailing Address - Phone:903-747-0869
Mailing Address - Fax:316-453-4173
Practice Address - Street 1:322 S LAURA AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-1517
Practice Address - Country:US
Practice Address - Phone:419-331-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04798-T101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty