Provider Demographics
NPI:1407130578
Name:IMPACT
Entity Type:Organization
Organization Name:IMPACT
Other - Org Name:CHR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:810-985-5168
Mailing Address - Street 1:1001 MILITARY ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5416
Mailing Address - Country:US
Mailing Address - Phone:810-985-5168
Mailing Address - Fax:800-248-1568
Practice Address - Street 1:1001 MILITARY ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5416
Practice Address - Country:US
Practice Address - Phone:810-985-5168
Practice Address - Fax:800-248-1568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801093360101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherFIN