Healthcare Provider Details

I. General information

NPI: 1750690749
Provider Name (Legal Business Name): SARA S REQUA LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2010
Last Update Date: 09/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 PINE ST
NEW CANAAN CT
06840-5425
US

IV. Provider business mailing address

165 ROSEBROOK RD
NEW CANAAN CT
06840-3726
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:
Title or Position:
Credential:
Phone: