Provider Demographics
NPI:1598105041
Name:DUTRA, SUNNY JUSTINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUNNY
Middle Name:JUSTINE
Last Name:DUTRA
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 1:500 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:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA11009103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty