Healthcare Provider Details

I. General information

NPI: 1386671279
Provider Name (Legal Business Name): SOUTH HAVEN BEHAVIORAL MODIFICATION II INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448-454 E. 61ST ST
CHICAGO IL
60637
US

IV. Provider business mailing address

4632 175TH PL
COUNTRY CLUB HILLS IL
60478-4531
US

V. Phone/Fax

Practice location:
  • Phone: 773-752-8602
  • Fax: 773-752-5824
Mailing address:
  • Phone: 708-785-6597
  • Fax: 706-206-0550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. DANTE PIMENTEL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 773-752-8602