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General NPI Number Information
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NPI Number | 1104521863
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Entity Type | Organization
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Legal Business Name | SECOND CHANCE RE-ENTRY INITIATIVE PROGRAM
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Dates
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Enumeration Date | 04/03/2023
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Last Update Date | 04/03/2023
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Provider Practice Location Address
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Address Line | 157 CHARTER OAK AVE
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City | HARTFORD
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State | CT
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Zip | 06106-1913
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Country | US
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Telephone | 860-400-2488
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Fax |
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Provider Business Mailing Address
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Address Line | 157 CHARTER OAK AVE
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City | HARTFORD
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State | CT
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Zip | 06106-1913
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Country | US
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Telephone | 860-400-2488
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Fax |
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | EDWARD ANDREWS
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Credential | BS
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Telephone | 860-879-1335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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