Healthcare Provider Details

I. General information

NPI: 1609071646
Provider Name (Legal Business Name): EMPACT-SUICIDE PREVENTION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 S. MADISON DRIVE
TEMPE AZ
85281-7248
US

IV. Provider business mailing address

618 S. MADISON DRIVE
TEMPE AZ
85281-7248
US

V. Phone/Fax

Practice location:
  • Phone: 480-784-1514
  • Fax: 480-967-3528
Mailing address:
  • Phone: 480-784-1514
  • Fax: 480-967-3528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH 373
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH-4062
License Number StateAZ

VIII. Authorized Official

Name: LIZ MONTANO
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 480-784-1514