Provider Demographics
NPI:1346961810
Name:AUDENINO, PAIGE TAYLOR (BS, MS)
Entity Type:Individual
Prefix:MRS
First Name:PAIGE
Middle Name:TAYLOR
Last Name:AUDENINO
Suffix:
Gender:F
Credentials:BS, MS
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:TAYLOR
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, MS
Mailing Address - Street 1:PO BOX 521
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-0521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7173 MANLIUS CENTER RD
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9534
Practice Address - Country:US
Practice Address - Phone:917-280-2946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-05
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011653-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health