Provider Demographics
NPI:1306197397
Name:VAN PAMEL, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:VAN PAMEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:SCIANDRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31 CLAIR ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-1705
Mailing Address - Country:US
Mailing Address - Phone:586-649-8672
Mailing Address - Fax:
Practice Address - Street 1:54 SENECA ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-2349
Practice Address - Country:US
Practice Address - Phone:248-836-0191
Practice Address - Fax:248-836-0199
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803085349101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)