1548743321 NPI number — ROXANNE PRUITT-KISER LCSW, LICSW

Table of content: ROXANNE PRUITT-KISER LCSW, LICSW (NPI 1548743321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548743321 NPI number — ROXANNE PRUITT-KISER LCSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUITT-KISER
Provider First Name:
ROXANNE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548743321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BLDG 4060 602ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAINWRIGHT
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-361-0229
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4060 602ND ST
Provider Second Line Business Practice Location Address:
BACH
Provider Business Practice Location Address City Name:
FORT WAINWRIGHT
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
73-617-2039
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C011676 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 32055 . This is a "LICSW" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: C011676 . This is a "LCSW" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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