Basic Information
| Provider Information | |||||||||
| NPI: | 1184974263 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHERRY STREET SERVICES INC | ||||||||
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| OtherOrganizationName: | WYOMING COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CHERRY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2929 BURLINGAME AVE SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495092609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658333 | ||||||||
| FaxNumber: | 6169405820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2012 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | BLACKMON | ||||||||
| AuthorizedOfficialFirstName: | TASHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6169658200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHERRY STREET SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TB0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TP2701X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 156FX1800X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.