Provider Demographics
NPI:1346924693
Name:SEMENOV, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:SEMENOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 CHAMBERS RD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-7117
Mailing Address - Country:US
Mailing Address - Phone:303-617-2300
Mailing Address - Fax:303-617-2344
Practice Address - Street 1:1544 ELMIRA ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80010-2116
Practice Address - Country:US
Practice Address - Phone:303-617-2300
Practice Address - Fax:303-617-2344
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0020532101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health