Healthcare Provider Details

I. General information

NPI: 1295589489
Provider Name (Legal Business Name): SECOND CHANCE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MORSE RD STE 110
COLUMBUS OH
43214-1879
US

IV. Provider business mailing address

700 MORSE RD STE 110
COLUMBUS OH
43214-1879
US

V. Phone/Fax

Practice location:
  • Phone: 614-468-1110
  • Fax:
Mailing address:
  • Phone: 614-468-1110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: HIBO ADEM
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 614-446-6772