MEDICARE: EMPACT - SUICIDE PREVENTION CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	OTC6353	AZ

General Provider Information

NPI Number	:	1538584149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMPACT - SUICIDE PREVENTION CENTER

Provider Business Mailing Address
First Line	:	618 S MADISON DR
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85281-7248
Country	:	US
Telephone Number	:	480-784-1514
Fax Number	:	480-736-4939

Provider Business Practice Location Address
First Line	:	2923 N 33RD AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85017-5201
Country	:	US
Telephone Number	:	602-393-3840
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	LAURA LARSON-HUFFAKER
Credential	:
Telephone Number	:	480-784-1514

Provider Enumeration Date	:	02/19/2014
Last Update Date	:	06/12/2017

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