Healthcare Provider Details

I. General information

NPI: 1134483464
Provider Name (Legal Business Name): SECOND GENESIS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 HARVARD ST NW
WASHINGTON DC
20009-4904
US

IV. Provider business mailing address

1320 HARVARD ST NW
WASHINGTON DC
20009-4904
US

V. Phone/Fax

Practice location:
  • Phone: 202-222-0120
  • Fax:
Mailing address:
  • Phone: 202-222-0120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberCRF-000125
License Number StateDC

VIII. Authorized Official

Name: MR. MARK SEGAL
Title or Position: DIRECTOR OF CLINICAL OPERATIONS
Credential: LCSW-C
Phone: 301-563-1545