Healthcare Provider Details

I. General information

NPI: 1609555218
Provider Name (Legal Business Name): CHERRY STREET SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 07/12/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 35TH ST SW
GRAND RAPIDS MI
49548-2100
US

IV. Provider business mailing address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8200
  • Fax:
Mailing address:
  • Phone: 616-965-8209
  • Fax: 616-940-5366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 15
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