Healthcare Provider Details

I. General information

NPI: 1629991146
Provider Name (Legal Business Name): BLACKBIRD RISING MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MASONS ISLAND RD UNIT 11
MYSTIC CT
06355-2958
US

IV. Provider business mailing address

320 INDIGO ST
MYSTIC CT
06355-1326
US

V. Phone/Fax

Practice location:
  • Phone: 503-440-3088
  • Fax:
Mailing address:
  • Phone: 503-440-3088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE MAE BUFFINGTON
Title or Position: OWNER
Credential: LCSW
Phone: 503-440-3088