Healthcare Provider Details

I. General information

NPI: 1841791357
Provider Name (Legal Business Name): PINE REST CHRISTIAN MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 68TH STREET SE
GRAND RAPIDS MI
49548
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-281-6372
  • Fax:
Mailing address:
  • Phone: 616-281-6372
  • Fax: 616-281-6459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSA0410417
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberSA0410417
License Number StateMI

VIII. Authorized Official

Name: DIANE FENNEMA
Title or Position: MANAGED CARE ADMINISTRATOR
Credential:
Phone: 616-281-6372