Provider Demographics
NPI:1750816211
Name:SAMSONOVA-JELLISON, OLGA VIKTOROVNA (MT-BC)
Entity Type:Individual
Prefix:MRS
First Name:OLGA
Middle Name:VIKTOROVNA
Last Name:SAMSONOVA-JELLISON
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3098 MACE AVE APT C
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2546
Mailing Address - Country:US
Mailing Address - Phone:714-308-1023
Mailing Address - Fax:
Practice Address - Street 1:3098 MACE AVE APT C
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-2546
Practice Address - Country:US
Practice Address - Phone:714-308-1023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
09262225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist