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General NPI Number Information
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NPI Number | 1124366745
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Entity Type | Organization
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Legal Business Name | REQUA PSYCHOTHERAPY LLC
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Dates
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Enumeration Date | 01/17/2013
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Last Update Date | 01/17/2013
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Provider Practice Location Address
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Address Line | 72 PARK ST SUITE 103
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City | NEW CANAAN
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State | CT
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Zip | 06840-4532
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Country | US
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Telephone | 203-803-0469
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1007
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City | SOUTHBURY
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State | CT
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Zip | 06488-4107
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Country | US
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Telephone | 203-803-0469
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Fax |
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Authorized Official
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Title or Position | OWNER/THERAPIST
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Name | SARA S REQUA
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Credential | LMFT
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Telephone | 203-803-0469
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 001415
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License Number State | CT
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