Provider Demographics
NPI:1760194617
Name:POLAMALU, MATTHEW AOATOA
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:AOATOA
Last Name:POLAMALU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:AOATOA
Other - Last Name:POLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:39899 BALENTINE DR STE 128
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-5361
Mailing Address - Country:US
Mailing Address - Phone:650-931-6300
Mailing Address - Fax:
Practice Address - Street 1:39899 BALENTINE DR STE 128
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-5361
Practice Address - Country:US
Practice Address - Phone:650-931-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician