MEDICARE: BLACK & MENTAL HEATLH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	104100000X	Social Worker
2	1041S0200X	School Social Worker
3	251S00000X	Community/Behavioral Health Agency
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
5	261QM0850X	Adult Mental Health Clinic/Center
6	261QM0855X	Adolescent and Children Mental Health Clinic/Center
7	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1881216968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK & MENTAL HEATLH, LLC

Provider Business Mailing Address
First Line	:	96 SILVER LN APT B7
Second Line	:
City	:	EAST HARTFORD
State	:	CT
Zip	:	06118-1006
Country	:	US
Telephone Number	:	203-536-3199
Fax Number	:

Provider Business Practice Location Address
First Line	:	96 SILVER LN APT B7
Second Line	:
City	:	EAST HARTFORD
State	:	CT
Zip	:	06118-1006
Country	:	US
Telephone Number	:	203-536-3199
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	JAYANN L PINTO-SAMUDA
Credential	:	LCSW
Telephone Number	:	203-536-3199

Provider Enumeration Date	:	05/12/2020
Last Update Date	:	05/12/2020

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Directions to “BLACK & MENTAL HEATLH, LLC ” Practice Location

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