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
1350 W CENTRE AVE, PORTAGE, MI 49024-5361
(269) 910-7327
(269) 910-7328
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
—
—
101YP2500X
Professional Counselor
—
—
103T00000X
Psychologist
—
—
104100000X
Social Worker
—
—
2084P0800X
Psychiatry Physician
—
—
283Q00000X
Psychiatric Hospital
Primary
1080000018
MI
324500000X
Substance Abuse Rehabilitation Facility
SA0390191
MI
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Enumeration date
03/05/2014
Last updated
11/04/2020
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