1093259301 NPI number — EMPACT - SUICIDE PREVENTION CENTER

Table of content: (NPI 1093259301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093259301 NPI number — EMPACT - SUICIDE PREVENTION CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMPACT - SUICIDE PREVENTION CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093259301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
618 S MADISON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMPE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85281-7248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-784-1514
Provider Business Mailing Address Fax Number:
480-967-3528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2474 E HUNT HWY
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
SAN TAN VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85143-5210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-784-1514
Provider Business Practice Location Address Fax Number:
480-967-3528
Provider Enumeration Date:
12/06/2016

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  OTC7423 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 084711 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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