Provider Demographics
NPI:1184635328
Name:PINE REST CHRISTIAN MENTAL HEALTH SERVICES
Entity Type:Organization
Organization Name:PINE REST CHRISTIAN MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:FENNEMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-281-6372
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:8333 FELCH STREET
Practice Address - Street 2:MEDICAL OFFICE BUILDING
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464
Practice Address - Country:US
Practice Address - Phone:616-741-3790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINE REST CHRISTIAN MENTAL HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-11
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP10D11275OtherMA, LLP/DOCTORAL
MI260D17625OtherPSYCHIATRIST
MI680D16189OtherPSYCHOLOGIST
MI800D16222OtherSOCIAL WORKER
MI500D11133OtherNURSE PRACTITIONER