Healthcare Provider Details

I. General information

NPI: 1811783079
Provider Name (Legal Business Name): THE PHOENIX CLINIC NFP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 W 18TH ST STE 325
CHICAGO IL
60608-2400
US

IV. Provider business mailing address

4955 S CALUMET AVE APT 4S
CHICAGO IL
60615-2275
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 TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

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