Organization
PINE REST CHRISTIAN MENTAL HEALTH SERVICES
Active
Parent organization
PINE REST LAKE ODESSA OFFICE
Other names
Pine Rest Lake Odessa Office
Organization subpart
Yes
Provider details
NPI number
Legal business name
PINE REST LAKE ODESSA OFFICE
Authorized official
DIANE P FENNEMA (MANAGED CARE ADMINISTRATOR)
(616) 281-6372
Entity
Organization
Contact information
Practice address
4294 LAUREL DR, LAKE ODESSA, MI 48849-9423
(616) 891-8770
Mailing address
300 68TH ST SE, GRAND RAPIDS, MI 49548-6927
(616) 455-5000
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
103T00000X
Psychologist
—
—
104100000X
Social Worker
—
—
2084P0800X
Psychiatry Physician
Primary
—
—
283Q00000X
Psychiatric Hospital
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Enumeration date
05/29/2008
Last updated
11/04/2020
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