Provider Demographics
NPI:1730492190
Name:GUSSOFF, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GUSSOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 17TH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1527
Mailing Address - Country:US
Mailing Address - Phone:510-628-9065
Mailing Address - Fax:
Practice Address - Street 1:519 17TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1527
Practice Address - Country:US
Practice Address - Phone:510-628-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health