Provider Demographics
NPI:1902579956
Name:SUNNY DUTRA, PH.D., LLC
Entity Type:Organization
Organization Name:SUNNY DUTRA, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUTRA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:617-302-6849
Mailing Address - Street 1:500 VICTORY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-3139
Mailing Address - Country:US
Mailing Address - Phone:617-302-6849
Mailing Address - Fax:
Practice Address - Street 1:500 VICTORY RD STE 400
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02171-3139
Practice Address - Country:US
Practice Address - Phone:617-302-6849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty