Provider Demographics
NPI:1992420608
Name:PRUITT, MANDY (PTA)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 W WILSON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2585
Mailing Address - Country:US
Mailing Address - Phone:615-505-8920
Mailing Address - Fax:
Practice Address - Street 1:350 W WILSON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2585
Practice Address - Country:US
Practice Address - Phone:615-505-8920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA0133882251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic