Healthcare Provider Details

I. General information

NPI: 1831040005
Provider Name (Legal Business Name): BLUE PHOENIX WELLNESS & COUNSELING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2026
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24586 W OAK ST
ROUND LAKE IL
60073-1428
US

IV. Provider business mailing address

24586 W OAK ST
ROUND LAKE IL
60073-1428
US

V. Phone/Fax

Practice location:
  • Phone: 224-250-1228
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARIYA BLUE
Title or Position: MENTAL HEALTH THERAPIST/PRESIDENT
Credential: LCSW
Phone: 224-250-1228