Basic Information
| Provider Information | |||||||||
| NPI: | 1104884154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRUIT | ||||||||
| FirstName: | MARY MOLLY | ||||||||
| MiddleName: | LOREN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TRAFFAS | ||||||||
| OtherFirstName: | MOLLY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LSCSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3425 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672034919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169460990 | ||||||||
| FaxNumber: | 3169431139 | ||||||||
| Practice Location | |||||||||
| Address1: | 3425 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672034919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169460990 | ||||||||
| FaxNumber: | 3169431139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 10/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2240 | KS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 100457290B | 05 | KS | MEDICAID | 070415 | 01 | KS | BCBS | OTHER |