Provider Demographics
NPI:1346917820
Name:VAN ETTEN, KIMBERLY N (LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:VAN ETTEN
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:PO BOX 223
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20134-0223
Mailing Address - Country:US
Mailing Address - Phone:678-520-0327
Mailing Address - Fax:
Practice Address - Street 1:170 W MAIN ST STE B6
Practice Address - Street 2:
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132-5829
Practice Address - Country:US
Practice Address - Phone:678-520-0327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010657101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional