Provider Demographics
NPI:1427352681
Name:SECOND GENESIS, INC.
Entity type:Organization
Organization Name:SECOND GENESIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGAL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:301-563-1545
Mailing Address - Street 1:8611 2ND AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3372
Mailing Address - Country:US
Mailing Address - Phone:301-563-1545
Mailing Address - Fax:301-563-1546
Practice Address - Street 1:107 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:CROWNSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21032-2061
Practice Address - Country:US
Practice Address - Phone:301-621-9013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD904039261Q00000X, 261QR0401X, 261QR0405X
MD1053589242324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder