Provider Demographics
NPI:1811783079
Name:THE PHOENIX CLINIC NFP
Entity type:Organization
Organization Name:THE PHOENIX CLINIC NFP
Other - Org Name:
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 1:4955 S CALUMET AVE APT 4S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-2275
Mailing Address - Country:US
Mailing Address - Phone:773-431-7397
Mailing Address - Fax:
Practice Address - Street 1:917 W 18TH ST STE 325
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-2400
Practice Address - Country:US
Practice Address - Phone:773-431-7397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE PHOENIX CLINIC NFP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health