Healthcare Provider Details

I. General information

NPI: 1144985250
Provider Name (Legal Business Name): BLACK QUIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 NICHOLS AVE
STRATFORD CT
06614-2627
US

IV. Provider business mailing address

1355 NICHOLS AVE
STRATFORD CT
06614-2627
US

V. Phone/Fax

Practice location:
  • Phone: 203-892-2921
  • Fax:
Mailing address:
  • Phone: 203-892-2921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: AUTUMN WRIGHT
Title or Position: OWNER
Credential:
Phone: 203-892-2921