Provider Demographics
NPI:1386671279
Name:SOUTH HAVEN BEHAVIORAL MODIFICATION II INC
Entity Type:Organization
Organization Name:SOUTH HAVEN BEHAVIORAL MODIFICATION II INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANTE
Authorized Official - Middle Name:
Authorized Official - Last Name:PIMENTEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-752-8602
Mailing Address - Street 1:4632 175TH PL
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-4531
Mailing Address - Country:US
Mailing Address - Phone:708-785-6597
Mailing Address - Fax:706-206-0550
Practice Address - Street 1:448-454 E. 61ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-752-8602
Practice Address - Fax:773-752-5824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty