Provider Demographics
NPI:1558103143
Name:PRUITT, BEN (LCSWA, MDIV)
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:PRUITT
Suffix:
Gender:U
Credentials:LCSWA, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5716 FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-9661
Mailing Address - Country:US
Mailing Address - Phone:919-748-4610
Mailing Address - Fax:
Practice Address - Street 1:5716 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-9661
Practice Address - Country:US
Practice Address - Phone:919-748-4610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0207161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical