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General NPI Number Information
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NPI Number | 1447554019
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Entity Type | Organization
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Legal Business Name | 2ND CHANCE MENTAL HEALTH CENTER, LLC
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Dates
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Enumeration Date | 12/22/2010
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Last Update Date | 12/22/2010
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Provider Practice Location Address
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Address Line | 1250 SE PORT ST LUCIE BLVD STE C
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34952-5385
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Country | US
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Telephone | 772-249-0880
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Fax | 772-249-0881
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Provider Business Mailing Address
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Address Line | 1250 SE PORT ST LUCIE BLVD STE C
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34952-5385
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Country | US
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Telephone | 772-249-0880
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Fax | 772-249-0881
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Authorized Official
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Title or Position | PRESIDENT
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Name | JEAN M LARSEN
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Credential | MSW
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Telephone | 772-249-0880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1956AD422201
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License Number State | FL
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