Healthcare Provider Details

I. General information

NPI: 1497454789
Provider Name (Legal Business Name): AMY MAUREEN SUTHERLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 BROADWAY
CAMBRIDGE MA
02139-1947
US

IV. Provider business mailing address

500 S 11TH AVE STE 400
POCATELLO ID
83201-4880
US

V. Phone/Fax

Practice location:
  • Phone: 617-758-8485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberSE-203981
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: