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General NPI Number Information
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NPI Number | 1902579956
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Entity Type | Organization
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Legal Business Name | SUNNY DUTRA, PH.D., LLC
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Dates
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Enumeration Date | 07/27/2021
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Last Update Date | 07/27/2021
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Provider Practice Location Address
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Address Line | 500 VICTORY RD STE 400
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City | QUINCY
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State | MA
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Zip | 02171-3139
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Country | US
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Telephone | 617-302-6849
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Fax |
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Provider Business Mailing Address
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Address Line | 500 VICTORY RD STE 400
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City | QUINCY
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State | MA
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Zip | 02171-3139
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Country | US
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Telephone | 617-302-6849
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL PSYCHOLOGIST
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Name | DR. SUNNY DUTRA
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Credential | PH.D.
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Telephone | 617-302-6849
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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