Healthcare Provider Details

I. General information

NPI: 1053750521
Provider Name (Legal Business Name): SECOND CHANCE COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 03/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13241 EXECUTIVE PARK TER
GERMANTOWN MD
20874-2648
US

IV. Provider business mailing address

PO BOX 882
CLARKSBURG MD
20871-0882
US

V. Phone/Fax

Practice location:
  • Phone: 301-972-1373
  • Fax: 301-972-1584
Mailing address:
  • Phone: 301-972-1373
  • Fax: 301-972-1584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX3109
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC5475
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC4709
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC4015
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12637
License Number StateMD
# 6
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number905516
License Number StateMD

VIII. Authorized Official

Name: TERESE HAYES
Title or Position: OWNER
Credential: LCSW-C
Phone: 301-972-1373