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	OTC7423	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093259301
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	:	480-967-3528

Provider Business Practice Location Address
First Line	:	2474 E HUNT HWY
Second Line	:	#100
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85143-5210
Country	:	US
Telephone Number	:	480-784-1514
Fax Number	:	480-967-3528

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

Provider Enumeration Date	:	12/06/2016
Last Update Date	:	06/09/2017

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