Healthcare Provider Details

I. General information

NPI: 1346600905
Provider Name (Legal Business Name): CHERRY STREET SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 OAK AVE
MUSKEGON MI
49442-2468
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: 616-940-5366
Mailing address:
  • Phone: 616-965-8200
  • Fax: 616-940-5366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: TASHA BLACKMON
Title or Position: CEO
Credential: CEO
Phone: 616-965-8215