Provider Demographics
NPI:1073673406
Name:PIMENTAL, PATRICIA A (PSYD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:PIMENTAL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 W PARK AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-3372
Mailing Address - Country:US
Mailing Address - Phone:708-643-4059
Mailing Address - Fax:844-273-7876
Practice Address - Street 1:180 W PARK AVE STE 260
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-3372
Practice Address - Country:US
Practice Address - Phone:708-643-4059
Practice Address - Fax:844-273-7876
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004014103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1673508OtherBCBS
IL1673508OtherBCBS