Healthcare Provider Details

I. General information

NPI: 1871421628
Provider Name (Legal Business Name): BRIANNA LAQUATRA LPCC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29329 WALDENSA AVE
WICKLIFFE OH
44092-2058
US

IV. Provider business mailing address

29329 WALDENSA AVE
WICKLIFFE OH
44092-2058
US

V. Phone/Fax

Practice location:
  • Phone: 440-269-0643
  • Fax:
Mailing address:
  • Phone: 440-269-0643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.2404435-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: