Provider Demographics
NPI:1487837506
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 ADMINISTATOR
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 1:300 68TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6927
Practice Address - Country:US
Practice Address - Phone:616-455-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINE REST CHRISTIAN MENTAL HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-12
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No283Q00000XHospitalsPsychiatric HospitalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOD16083OtherBC/BS PSYCHIATRY-MULTI SP
MIOD16222OtherBC/BS SOCIAL WORKER
MIOD14837OtherBC/BS GNERAL MEDICINE
MIOD17625OtherBC/BS PSYCHIATRY
MIOD16189OtherBC/BS PSYCHOLOGIST
MIOD11275OtherBC/BS MA, LLP, DOCTORAL
MIOD11133OtherBC/BS NURSE PRACTIONER
MIOD14836OtherBC/BS PEDIATRICS