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General NPI Number Information
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NPI Number | 1518299791
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Entity Type | Organization
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Legal Business Name | NEW OUTLOOK..SECOND CHANCE, INC.
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Dates
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Enumeration Date | 02/12/2010
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Last Update Date | 08/29/2012
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Provider Practice Location Address
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Address Line | 2604 CARVER ST SUITE C
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City | DURHAM
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State | NC
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Zip | 27705-2796
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Country | US
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Telephone | 919-682-4771
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Fax | 919-683-2641
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Provider Business Mailing Address
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Address Line | PO BOX 802
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City | DURHAM
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State | NC
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Zip | 27702-0802
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Country | US
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Telephone | 919-682-4771
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Fax | 919-683-2641
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MS. BETHENA M JACKSON
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Credential | BA, CSAC
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Telephone | 919-682-4771
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | 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 | 103T00000X
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Taxonomy Name | Psychologist
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | MHL-032-506
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License Number State | NC
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