Organization
PINE REST CHRISTIAN MENTAL HEALTH 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
243 68TH ST SE, GRAND RAPIDS, MI 49548-6924
(616) 281-6836
Mailing address
300 68TH ST SE, GRAND RAPIDS, MI 49548-6927
(616) 455-5000
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
101YM0800X
Mental Health Counselor
—
—
103T00000X
Psychologist
—
—
104100000X
Social Worker
—
—
207R00000X
Internal Medicine Physician
—
—
207RA0401X
Addiction Medicine (Internal Medicine) Physician
Primary
—
—
324500000X
Substance Abuse Rehabilitation Facility
410334
MI
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
750920290
BCBS DETOX
MI
Enumeration date
06/12/2007
Last updated
11/04/2020
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