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General NPI Number Information
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NPI Number | 1386671279
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Entity Type | Organization
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Legal Business Name | SOUTH HAVEN BEHAVIORAL MODIFICATION II INC
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Dates
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Enumeration Date | 06/27/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 448-454 E. 61ST ST
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City | CHICAGO
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State | IL
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Zip | 60637
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Country | US
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Telephone | 773-752-8602
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Fax | 773-752-5824
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Provider Business Mailing Address
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Address Line | 4632 175TH PL
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City | COUNTRY CLUB HILLS
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State | IL
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Zip | 60478-4531
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Country | US
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Telephone | 708-785-6597
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Fax | 706-206-0550
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DANTE PIMENTEL
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Credential | M.D.
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Telephone | 773-752-8602
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number |
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License Number State |
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