Provider Demographics
NPI:1073911293
Name:EMPACT - SUICIDE PREVENTION CENTER
Entity Type:Organization
Organization Name:EMPACT - SUICIDE PREVENTION CENTER
Other - Org Name:LA FRONTERA EMPACT-SPC
Other - Org Type:Doing Business As
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:LPC
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:480-736-4939
Practice Address - Street 1:21476 N JOHN WAYNE PKWY
Practice Address - Street 2:SUITE C101
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85139-8983
Practice Address - Country:US
Practice Address - Phone:520-316-6068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC14160251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health