=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164508875
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPACT-SPC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4425 W OLIVE AVE SUITE 194
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85302-3843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-784-1514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6629 N 90TH DR
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85305-2043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-872-7468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY THERAPIST
-----------------------------------------------------
Name | PROF. SONDRA KAY WILKINSON
-----------------------------------------------------
Credential | MC, NCC, LISAC, LPC
-----------------------------------------------------
Telephone | 480-784-1514
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LPC-12392
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------