Basic Information
| Provider Information | |||||||||
| NPI: | 1598138810 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINE REST CHRISTIAN MENTAL HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 68TH ST SE | ||||||||
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| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495486927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164555270 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1870 LEONARD ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495055650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169569619 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2015 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | FENNEMA | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGED CARE ADMINISTATOR | ||||||||
| AuthorizedOfficialTelephone: | 6162816372 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103T00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 104100000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 2084P0800X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 363L00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.