Provider Demographics
NPI:1932223302
Name:SOUTHEAST SECOND CHANCE, INC
Entity Type:Organization
Organization Name:SOUTHEAST SECOND CHANCE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUWYS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:912-265-2055
Mailing Address - Street 1:PO BOX 2727
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31521-2727
Mailing Address - Country:US
Mailing Address - Phone:912-265-2055
Mailing Address - Fax:912-265-2509
Practice Address - Street 1:600 G ST STE 6
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-6727
Practice Address - Country:US
Practice Address - Phone:912-265-2055
Practice Address - Fax:912-265-2509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0032871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA851663137AMedicaid
GA851663137AMedicaid
GAGRP8116Medicare UPIN