Provider Demographics
NPI:1467293357
Name:EMPACT - SUICIDE PREVENTION CENTER
Entity type:Organization
Organization Name:EMPACT - SUICIDE PREVENTION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:RASMUSSEN
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:
Practice Address - Street 1:1035 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-2295
Practice Address - Country:US
Practice Address - Phone:602-251-0650
Practice Address - Fax:602-251-0632
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMPACT - SUICIDE PREVENTION CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ589359Medicaid