Healthcare Provider Details

I. General information

NPI: 1881216968
Provider Name (Legal Business Name): BLACK & MENTAL HEATLH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 SILVER LN APT B7
EAST HARTFORD CT
06118-1006
US

IV. Provider business mailing address

96 SILVER LN APT B7
EAST HARTFORD CT
06118-1006
US

V. Phone/Fax

Practice location:
  • Phone: 203-536-3199
  • Fax:
Mailing address:
  • Phone: 203-536-3199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JAYANN L PINTO-SAMUDA
Title or Position: THERAPIST
Credential: LCSW
Phone: 203-536-3199