Provider Demographics
NPI:1689562860
Name:POLUSSA, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:POLUSSA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6868 CASTLEROCK DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-4713
Mailing Address - Country:US
Mailing Address - Phone:408-209-4615
Mailing Address - Fax:
Practice Address - Street 1:631 RIVER OAKS PKWY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-1907
Practice Address - Country:US
Practice Address - Phone:408-914-3851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-25
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty