Organization
PINE REST CHRISTIAN MENTAL HEALTH SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DIANE FENNEMA (MANAGED CARE ADMINISTRATOR)
(616) 281-6372
Entity
Organization
Contact information
Practice address
300 68TH ST SE, GRAND RAPIDS, MI 49548-6927
(616) 455-5000
Mailing address
300 68TH ST SE, GRAND RAPIDS, MI 49548-6927
(616) 455-5000
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
—
—
103G00000X
Clinical Neuropsychologist
—
—
103T00000X
Psychologist
Primary
—
—
104100000X
Social Worker
—
—
207R00000X
Internal Medicine Physician
—
—
208000000X
Pediatrics Physician
—
—
2084P0800X
Psychiatry Physician
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Enumeration date
02/14/2007
Last updated
11/04/2020
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