Provider Demographics
NPI:1295589489
Name:SECOND CHANCE THERAPY
Entity type:Organization
Organization Name:SECOND CHANCE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HIBO
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEM
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:614-446-6772
Mailing Address - Street 1:5938 BROOMWOOD LOOP S
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230-8500
Mailing Address - Country:US
Mailing Address - Phone:614-446-6772
Mailing Address - Fax:
Practice Address - Street 1:5938 BROOMWOOD LOOP S
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43230-8500
Practice Address - Country:US
Practice Address - Phone:614-446-6772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)