Provider Demographics
NPI:1073083150
Name:POLACHERIL, NITA
Entity Type:Individual
Prefix:
First Name:NITA
Middle Name:
Last Name:POLACHERIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 KILLIAN CT
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-3189
Mailing Address - Country:US
Mailing Address - Phone:832-606-2565
Mailing Address - Fax:
Practice Address - Street 1:445 LEIGH AVE
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-4000
Practice Address - Country:US
Practice Address - Phone:866-227-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-18-32514103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty