Provider Demographics
NPI:1174816615
Name:KUTSUNAI, SALLY (PHD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:KUTSUNAI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90406-0208
Mailing Address - Country:US
Mailing Address - Phone:310-948-3015
Mailing Address - Fax:310-394-2409
Practice Address - Street 1:2790 SKYPARK DR
Practice Address - Street 2:STE 307
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5388
Practice Address - Country:US
Practice Address - Phone:310-948-3015
Practice Address - Fax:310-394-2409
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23945103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist