Provider Demographics
NPI:1124366745
Name:REQUA PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:REQUA PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:S
Authorized Official - Last Name:REQUA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:203-803-0469
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-4107
Mailing Address - Country:US
Mailing Address - Phone:203-803-0469
Mailing Address - Fax:
Practice Address - Street 1:72 PARK ST
Practice Address - Street 2:SUITE 103
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-4532
Practice Address - Country:US
Practice Address - Phone:203-803-0469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001415106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty