Provider Demographics
NPI:1720654023
Name:PRUETT, MITCHELL (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:PRUETT
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 EMPIRE DR APT 3225
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-0068
Mailing Address - Country:US
Mailing Address - Phone:785-577-4120
Mailing Address - Fax:
Practice Address - Street 1:14651 DALLAS PKWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-8856
Practice Address - Country:US
Practice Address - Phone:866-919-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116202235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist