Provider Demographics
NPI:1003982133
Name:EMPACT-SUICIDE PREVENTION CENTER
Entity Type:Organization
Organization Name:EMPACT-SUICIDE PREVENTION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON-HUFFAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:480-784-1514
Mailing Address - Street 1:618 S. MADISON DRIVE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-7248
Mailing Address - Country:US
Mailing Address - Phone:480-784-1514
Mailing Address - Fax:480-967-3528
Practice Address - Street 1:618 S. MADISON DRIVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-7248
Practice Address - Country:US
Practice Address - Phone:480-784-1514
Practice Address - Fax:480-967-3528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-373251S00000X
AZBH 1958251S00000X
AZBH-4062251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ100587Medicaid
AZ622987Medicaid
AZ100587Medicaid
Z138601Medicare PIN