Provider Demographics
NPI:1043592629
Name:CHERRY STREET SERVICES INC
Entity Type:Organization
Organization Name:CHERRY STREET SERVICES INC
Other - Org Name:LEONARD STREET COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-776-2121
Mailing Address - Street 1:100 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4748
Mailing Address - Country:US
Mailing Address - Phone:616-965-8200
Mailing Address - Fax:
Practice Address - Street 1:1400 LEONARD STREET NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5515
Practice Address - Country:US
Practice Address - Phone:616-954-1991
Practice Address - Fax:616-954-1998
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHERRY STREET SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-09
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231974Medicare Oscar/Certification
MI0D16477Medicare PIN