=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922455609
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SECOND CHANCE COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2016
-----------------------------------------------------
Last Update Date | 05/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 719 W APACHE ST
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87401-5512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-427-1621
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 719 W APACHE ST
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87401-5512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-427-1621
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ALISHA KATHRYN HAWTHORNE
-----------------------------------------------------
Credential | LCSW, LADAC
-----------------------------------------------------
Telephone | 505-427-1621
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 5211247
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 5211247
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 5211247
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------