Provider Demographics
NPI:1689435133
Name:SYDORENKO, OLENA X (MT)
Entity type:Individual
Prefix:
First Name:OLENA
Middle Name:
Last Name:SYDORENKO
Suffix:X
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 TANGLE BRUSH DR APT 98
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-2939
Mailing Address - Country:US
Mailing Address - Phone:346-256-5325
Mailing Address - Fax:
Practice Address - Street 1:19075 INTERSTATE 45 S STE 250
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385-8701
Practice Address - Country:US
Practice Address - Phone:346-256-5325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX131981225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist