Healthcare Provider Details

I. General information

NPI: 1316632672
Provider Name (Legal Business Name): THE PHOENIX CLINIC NFP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 S DELANO CT W STE B201
CHICAGO IL
60605-3734
US

IV. Provider business mailing address

2436 W CULLOM AVE
CHICAGO IL
60618-1604
US

V. Phone/Fax

Practice location:
  • Phone: 773-431-7397
  • Fax:
Mailing address:
  • Phone: 773-431-7397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TAYLOR ARIEL PETTWAY
Title or Position: EXECUTIVE DIRECTOR
Credential: LMFT
Phone: 773-431-7397