Organization
PINE REST CHRISTIAN MENTAL HEATTH SERVICES
Active
Organization
PINE REST CHRISTIAN MENTAL HEATTH SERVICES
Active
Parent organization
PINE REST CHRISTIAN MENTAL HEALTH SERVICES
Organization subpart
Yes
Provider details
NPI number
Legal business name
PINE REST CHRISTIAN MENTAL HEALTH SERVICES
Authorized official
DIANE FENNEMA (MANAGED CARE ADMINISTRATOR)
(616) 281-6372
Entity
Organization
Contact information
Practice address
310 LAFAYETTE AVE SE, GRAND RAPIDS, MI 49503-4693
(616) 913-1400
Mailing address
300 68TH ST SE, GRAND RAPIDS, MI 49548-6927
(616) 455-5000
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
—
—
104100000X
Social Worker
—
—
2084P0800X
Psychiatry Physician
Primary
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
260D17625
PSYCHIATRISTS
MI
01
—
500D11133
NURSE PRACT.
MI
01
—
680D16189
PSYCHOLOGISTS
MI
01
—
800D16222
SOCIAL WORKERS
MI
01
—
P10D11275
PSYCHOLGOGISTS-MA, DOCTOR
MI
Enumeration date
08/07/2006
Last updated
11/04/2020
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