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General NPI Number Information
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NPI Number | 1568040368
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Entity Type | Organization
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Legal Business Name | PINE REST CHRISTIAN MENTAL HEALTH SERVICES
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Dates
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Enumeration Date | 04/01/2021
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Last Update Date | 03/11/2022
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Provider Practice Location Address
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Address Line | 300 68TH ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49548-6927
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Country | US
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Telephone | 616-281-6372
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Fax | 616-281-6459
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Provider Business Mailing Address
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Address Line | 300 68TH ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49548-6927
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Country | US
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Telephone | 616-281-6372
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Fax | 616-281-6459
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Authorized Official
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Title or Position | MANAGED CARE ADMINISTRATOR
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Name | DIANE M FENNEMA
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Credential |
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Telephone | 616-281-6372
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #12
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #13
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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