Provider Demographics
NPI:1053049734
Name:PRUITT, MARIA DARNICE
Entity type:Individual
Prefix:MISS
First Name:MARIA
Middle Name:DARNICE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2949 HURLBUT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-2103
Mailing Address - Country:US
Mailing Address - Phone:313-978-4287
Mailing Address - Fax:
Practice Address - Street 1:12051 WAYBURN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1037
Practice Address - Country:US
Practice Address - Phone:313-778-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0000000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0000000Medicaid