Provider Demographics
NPI:1104884154
Name:PRUIT, MARY MOLLY LOREN
Entity type:Individual
Prefix:
First Name:MARY MOLLY
Middle Name:LOREN
Last Name:PRUIT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:L
Other - Last Name:TRAFFAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSCSW
Mailing Address - Street 1:3425 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-4919
Mailing Address - Country:US
Mailing Address - Phone:316-946-0990
Mailing Address - Fax:316-943-1139
Practice Address - Street 1:3425 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-4919
Practice Address - Country:US
Practice Address - Phone:316-946-0990
Practice Address - Fax:316-943-1139
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS22401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100457290BMedicaid
KS070415OtherBCBS
KS070415OtherBCBS
KS100457290BMedicaid