Basic Information
| Provider Information | |||||||||
| NPI: | 1578979274 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHERRY STREET HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CHERRY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658200 | ||||||||
| FaxNumber: | 6169405357 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 CHERRY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658200 | ||||||||
| FaxNumber: | 6169405357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2014 | ||||||||
| LastUpdateDate: | 07/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | BUXTON | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | SUPPORTS COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6169658200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LLBSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 6802088180 | MI | Y | Agencies | Case Management |
No ID Information.