Provider Demographics
NPI:1699836734
Name:PRUITT, DIANA LYNN (LCSW, CCADC)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:LYNN
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LCSW, CCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:IRONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35210-1013
Mailing Address - Country:US
Mailing Address - Phone:404-423-6262
Mailing Address - Fax:
Practice Address - Street 1:2302 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:IRONDALE
Practice Address - State:AL
Practice Address - Zip Code:35210-1013
Practice Address - Country:US
Practice Address - Phone:404-423-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0034331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA181768916AMedicaid
AL4011COtherLCSW LICENSE
IN34008849AOtherLCSW LICENSE