Healthcare Provider Details

I. General information

NPI: 1720324437
Provider Name (Legal Business Name): KARISSA H. REQUA C.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2012
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6508 S ACOMA ST
LITTLETON CO
80120-3413
US

IV. Provider business mailing address

8357 N RAMPART RANGE RD SUITE #A205
LITTLETON CO
80125-9365
US

V. Phone/Fax

Practice location:
  • Phone: 720-339-1724
  • Fax: 303-932-1363
Mailing address:
  • Phone: 720-339-1724
  • Fax: 303-932-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3800
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: