MEDICARE: SECOND CHANCE COUNSELING SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization	4068	SC
2	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518023076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SECOND CHANCE COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	108 STAGE COACH LANE
Second Line	:	VILLAGE PARK
City	:	ORANGEBURG
State	:	SC
Zip	:	29118-2499
Country	:	US
Telephone Number	:	803-516-0200
Fax Number	:	803-516-8288

Provider Business Practice Location Address
First Line	:	108 STAGE COACH LANE
Second Line	:	VILLAGE PARK
City	:	ORANGEBURG
State	:	SC
Zip	:	29118-2499
Country	:	US
Telephone Number	:	803-516-0200
Fax Number	:	803-516-8288

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. JAMES FURTICK JR.
Credential	:	PH.D
Telephone Number	:	803-516-0200

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	04/27/2023

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