Healthcare Provider Details

I. General information

NPI: 1285680645
Provider Name (Legal Business Name): PHOENIX HEALTHCARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7324 N WESTERN AVE
CHICAGO IL
60645-1814
US

IV. Provider business mailing address

1941 GOVERNORS
HOFFMAN ESTATES IL
60169
US

V. Phone/Fax

Practice location:
  • Phone: 773-465-4555
  • Fax: 773-465-4552
Mailing address:
  • Phone: 847-310-3555
  • Fax: 773-751-2225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. JOEL MOSTOW
Title or Position: DELEGATED OFFICIAL
Credential: MD
Phone: 773-465-4555