Healthcare Provider Details

I. General information

NPI: 1124366745
Provider Name (Legal Business Name): REQUA PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 PARK ST SUITE 103
NEW CANAAN CT
06840-4532
US

IV. Provider business mailing address

PO BOX 1007
SOUTHBURY CT
06488-4107
US

V. Phone/Fax

Practice location:
  • Phone: 203-803-0469
  • Fax:
Mailing address:
  • Phone: 203-803-0469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001415
License Number StateCT

VIII. Authorized Official

Name: SARA S REQUA
Title or Position: OWNER/THERAPIST
Credential: LMFT
Phone: 203-803-0469