Basic Information
| Provider Information | |||||||||
| NPI: | 1063917862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IVANOVA | ||||||||
| FirstName: | AMBER | ||||||||
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| Credential: | LCSW, LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 S PUBLIC RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800267093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036653036 | ||||||||
| FaxNumber: | 3036653397 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 13TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803044104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034496050 | ||||||||
| FaxNumber: | 7205654132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2018 | ||||||||
| LastUpdateDate: | 05/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | ACD.0000931 | CO | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | CSW.09925143 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.