Provider Demographics
NPI:1841350113
Name:VAN VOOLEN, AUDREY HOPE (PHD)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:HOPE
Last Name:VAN VOOLEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:VAN VOOLEN
Other - Last Name:KISSEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:3460 COUNTRY LINE ROAD
Mailing Address - Street 2:
Mailing Address - City:SKANEATELES
Mailing Address - State:NY
Mailing Address - Zip Code:13152
Mailing Address - Country:US
Mailing Address - Phone:315-415-0157
Mailing Address - Fax:
Practice Address - Street 1:3460 COUNTRY LINE ROAD
Practice Address - Street 2:
Practice Address - City:SKANEATELES
Practice Address - State:NY
Practice Address - Zip Code:13152
Practice Address - Country:US
Practice Address - Phone:315-415-0157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015308-1103TC0700X
NY015308103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical