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General NPI Number Information
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NPI Number | 1144985250
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Entity Type | Organization
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Legal Business Name | BLACK QUIN LLC
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Dates
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Enumeration Date | 11/03/2021
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Last Update Date | 03/12/2025
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Provider Practice Location Address
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Address Line | 1355 NICHOLS AVE
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City | STRATFORD
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State | CT
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Zip | 06614-2627
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Country | US
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Telephone | 203-892-2921
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Fax |
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Provider Business Mailing Address
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Address Line | 1355 NICHOLS AVE
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City | STRATFORD
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State | CT
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Zip | 06614-2627
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Country | US
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Telephone | 203-892-2921
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AUTUMN WRIGHT
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Credential |
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Telephone | 203-892-2921
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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