Healthcare Provider Details

I. General information

NPI: 1184015539
Provider Name (Legal Business Name): CHERRY STREET SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4873 16 MILE RD NE
CEDAR SPRINGS MI
49319-8435
US

IV. Provider business mailing address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

V. Phone/Fax

Practice location:
  • Phone: 616-696-7330
  • Fax: 616-696-3123
Mailing address:
  • Phone: 616-965-8200
  • Fax: 616-940-5366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: TASHA BLACKMON
Title or Position: CEO
Credential:
Phone: 616-965-8200