MEDICARE: THE PHOENIX CLINIC NFP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1811783079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE PHOENIX CLINIC NFP

Provider Business Mailing Address
First Line	:	4955 S CALUMET AVE APT 4S
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-2275
Country	:	US
Telephone Number	:	773-431-7397
Fax Number	:

Provider Business Practice Location Address
First Line	:	917 W 18TH ST STE 325
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-2400
Country	:	US
Telephone Number	:	773-431-7397
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	TAYLOR ARIEL PETTWAY
Credential	:	LMFT
Telephone Number	:	773-431-7397

Provider Enumeration Date	:	04/15/2025
Last Update Date	:	12/16/2025

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