Provider Demographics
NPI:1174808539
Name:PRUKS, MARI (LMSW)
Entity type:Individual
Prefix:MISS
First Name:MARI
Middle Name:
Last Name:PRUKS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2676 ASPEN RIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-8927
Mailing Address - Country:US
Mailing Address - Phone:734-352-0637
Mailing Address - Fax:
Practice Address - Street 1:2723 S. STATE STREET
Practice Address - Street 2:SUITE 150
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-6188
Practice Address - Country:US
Practice Address - Phone:734-330-8932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-18
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010901281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0960419OtherBCBS