Basic Information
| Provider Information | |||||||||
| NPI: | 1124171954 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINE REST CHRISTIAN MENTAL HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 68TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495486927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164555000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1050 SILVER DR | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496845749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319472255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | FENNEMA | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGED CARE ADMINISTATOR | ||||||||
| AuthorizedOfficialTelephone: | 6162816372 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PINE REST CHRISTIAN MENTAL HEALTH SERVICES | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 103G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 1041S0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 283Q00000X | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 260D17625 | 01 | MI | BCBS PSYCHIATRIST | OTHER | 680D16189 | 01 | MI | PSYCHOLOGISTS | OTHER | P10D11275 | 01 | MI | PSYCHOLOGISTS-DOCTORAL LL | OTHER | 110D148370 | 01 | MI | INTERNAL MEDICINE | OTHER | 350D148360 | 01 | MI | PEDIATRICS | OTHER | 500D11133 | 01 | MI | NURSE PRACTIONERS | OTHER | 800D16222 | 01 | MI | SOCIAL WORKERS | OTHER | PSYCHIATIRSTS | 01 | MI | MULTISPECIALTY | OTHER |