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General NPI Number Information
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NPI Number | 1073911293
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Entity Type | Organization
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Legal Business Name | EMPACT - SUICIDE PREVENTION CENTER
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Dates
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Enumeration Date | 12/22/2014
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Last Update Date | 03/24/2022
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Provider Practice Location Address
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Address Line | 21476 N JOHN WAYNE PKWY SUITE C101
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City | MARICOPA
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State | AZ
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Zip | 85139-8983
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Country | US
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Telephone | 520-316-6068
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Fax |
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Provider Business Mailing Address
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Address Line | 618 S MADISON DR
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City | TEMPE
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State | AZ
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Zip | 85281-7248
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Country | US
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Telephone | 480-784-1514
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Fax | 480-736-4939
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | LAURA LARSON-HUFFAKER
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Credential | LPC
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Telephone | 480-784-1514
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LPC14160
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License Number State | AZ
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