Provider Demographics
NPI:1720324437
Name:REQUA, KARISSA H (CMT)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:H
Last Name:REQUA
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8357 N RAMPART RANGE RD
Mailing Address - Street 2:SUITE #A205
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80125-9365
Mailing Address - Country:US
Mailing Address - Phone:720-339-1724
Mailing Address - Fax:303-932-1363
Practice Address - Street 1:6508 S ACOMA ST
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-3413
Practice Address - Country:US
Practice Address - Phone:720-339-1724
Practice Address - Fax:303-932-1363
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-27
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3800225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist