Provider Demographics
NPI:1023553211
Name:EMPACT - SUICIDE PREVENTION CENTER
Entity Type:Organization
Organization Name:EMPACT - SUICIDE PREVENTION CENTER
Other - Org Name:TEMPE COMPREHENSIVE COMMUNITY HEALTH PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON-HUFFAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-784-1514
Mailing Address - Street 1:618 S MADISON DR
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 DR
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:2016-12-27
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC6752251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ756486Medicaid