Provider Demographics
NPI:1326377425
Name:LEQUIRE, AMY C (BCBA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:C
Last Name:LEQUIRE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 HATCHETTS HILL RD
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1512
Mailing Address - Country:US
Mailing Address - Phone:860-434-4800
Mailing Address - Fax:860-434-4834
Practice Address - Street 1:44 HATCHETTS HILL RD
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-1512
Practice Address - Country:US
Practice Address - Phone:860-434-4800
Practice Address - Fax:860-434-4834
Is Sole Proprietor?:No
Enumeration Date:2009-12-18
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-06-3006103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1922123314OtherFACILITY NPI
CT060883604OtherTAX ID