Provider Demographics
NPI:1558459164
Name:CHERRY STREET SERVICES, INC.
Entity Type:Organization
Organization Name:CHERRY STREET SERVICES, INC.
Other - Org Name:CHERRY STREET HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-965-8215
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:49503-4526
Mailing Address - Country:US
Mailing Address - Phone:616-235-7272
Mailing Address - Fax:616-235-7506
Practice Address - Street 1:550 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4748
Practice Address - Country:US
Practice Address - Phone:616-235-7289
Practice Address - Fax:616-235-0739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103TB0200X, 103TC0700X, 103TP2701X, 122300000X, 133V00000X, 207Q00000X, 207R00000X, 207W00000X, 208000000X, 261QF0400X
MI104100000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231809Medicare Oscar/Certification