Basic Information
| Provider Information | |||||||||
| NPI: | 1437219870 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEUROBEHAVIORAL MEDICINE CONSULTANTS LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 W PARK AVE STE 260 | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601263372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086434059 | ||||||||
| FaxNumber: | 8442737876 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 W PARK AVE STE 260 | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601263372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086434059 | ||||||||
| FaxNumber: | 8442737876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 02/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | PIMENTAL | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7086434059 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 071004014 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 252600 | 01 | IL | MEDICARE PTAN | OTHER |