Provider Demographics
NPI:1316632672
Name:THE PHOENIX CLINIC NFP
Entity type:Organization
Organization Name:THE PHOENIX CLINIC NFP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:ARIEL
Authorized Official - Last Name:PETTWAY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:773-431-7397
Mailing Address - Street 1:2436 W CULLOM AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1604
Mailing Address - Country:US
Mailing Address - Phone:773-431-7397
Mailing Address - Fax:
Practice Address - Street 1:1136 S DELANO CT W STE B201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3734
Practice Address - Country:US
Practice Address - Phone:773-431-7397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)