Provider Demographics
NPI:1366867525
Name:PRUITT, RUSTEE DANIELLE (LPC)
Entity type:Individual
Prefix:
First Name:RUSTEE
Middle Name:DANIELLE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4308 S GRAND ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-6322
Mailing Address - Country:US
Mailing Address - Phone:870-406-0077
Mailing Address - Fax:
Practice Address - Street 1:4308 S GRAND ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-6322
Practice Address - Country:US
Practice Address - Phone:870-406-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1607084101YM0800X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116378726Medicaid