Provider Demographics
NPI:1104397967
Name:CHEMODAKOV, SERAPHIM (MA LAC)
Entity Type:Individual
Prefix:
First Name:SERAPHIM
Middle Name:
Last Name:CHEMODAKOV
Suffix:
Gender:M
Credentials:MA LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 IRENE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731-2417
Mailing Address - Country:US
Mailing Address - Phone:732-580-1586
Mailing Address - Fax:
Practice Address - Street 1:15 W PROSPECT ST STE 2
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-2161
Practice Address - Country:US
Practice Address - Phone:732-254-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00445600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health