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General NPI Number Information
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NPI Number | 1316632672
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Entity Type | Organization
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Legal Business Name | THE PHOENIX CLINIC NFP
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Dates
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Enumeration Date | 04/11/2023
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Last Update Date | 04/11/2023
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Provider Practice Location Address
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Address Line | 1136 S DELANO CT W STE B201
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City | CHICAGO
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State | IL
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Zip | 60605-3734
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Country | US
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Telephone | 773-431-7397
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Fax |
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Provider Business Mailing Address
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Address Line | 2436 W CULLOM AVE
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City | CHICAGO
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State | IL
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Zip | 60618-1604
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Country | US
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Telephone | 773-431-7397
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | TAYLOR ARIEL PETTWAY
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Credential | LMFT
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Telephone | 773-431-7397
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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