Provider Demographics
NPI:1982239331
Name:FIDANOVA, ELENA (CMT)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:FIDANOVA
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 ST JOHNS CT
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-3512
Mailing Address - Country:US
Mailing Address - Phone:650-255-1155
Mailing Address - Fax:
Practice Address - Street 1:33 ST JOHNS CT
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-3512
Practice Address - Country:US
Practice Address - Phone:650-255-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74934225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist