Provider Demographics
NPI:1669657466
Name:SOUTH SHORE BEHAVIORAL CONSULTANTS
Entity Type:Organization
Organization Name:SOUTH SHORE BEHAVIORAL CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:QMHP
Authorized Official - Phone:708-333-0045
Mailing Address - Street 1:369 E 147TH ST STE E
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-2593
Mailing Address - Country:US
Mailing Address - Phone:708-333-0045
Mailing Address - Fax:708-333-0053
Practice Address - Street 1:369 EAST 147TH STREET SUITE E
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426
Practice Address - Country:US
Practice Address - Phone:708-333-0045
Practice Address - Fax:708-333-0053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210865Medicare Oscar/Certification