Provider Demographics
NPI:1104521863
Name:SECOND CHANCE RE-ENTRY INITIATIVE PROGRAM
Entity type:Organization
Organization Name:SECOND CHANCE RE-ENTRY INITIATIVE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:860-879-1335
Mailing Address - Street 1:157 CHARTER OAK AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1913
Mailing Address - Country:US
Mailing Address - Phone:860-400-2488
Mailing Address - Fax:
Practice Address - Street 1:157 CHARTER OAK AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1913
Practice Address - Country:US
Practice Address - Phone:860-400-2488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SECOND CHANCE RE-ENTRY INITIATIVE PROGRAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)