Provider Demographics
NPI:1386981850
Name:PRUITT, LARRY D (PHD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:PRUITT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9933 W HAYES ST MADIGAN ANX
Mailing Address - Street 2:JOINT BASE LEWIS MCCHORD
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-986-2946
Mailing Address - Fax:
Practice Address - Street 1:9933 W HAYES ST MADIGAN ANX
Practice Address - Street 2:JOINT BASE LEWIS MCCHORD
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-986-2946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60239205103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical