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NPI Code Detail

MEDICARE: CHERRY STREET SERVICES INC

MEDICARE: CHERRY STREET SERVICES INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) Counselor
2101YM0800XMental Health Counselor
3103TA0400XAddiction (Substance Use Disorder) Psychologist
4103TC0700XClinical Psychologist
51041C0700XClinical Social Worker
6163W00000XRegistered Nurse
7207LA0401XAddiction Medicine (Anesthesiology) Physician
8261QF0400XFederally Qualified Health Center (FQHC)

General Provider Information

NPI Number : 1386926004
Entity Type Code : Organization
Provider Name (Legal Business Name) : CHERRY STREET SERVICES INC
Provider Business Mailing Address
First Line : 100 CHERRY ST SE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49503-4526
Country : US
Telephone Number : 616-965-8200
Fax Number :
Provider Business Practice Location Address
First Line : 2303 KALAMAZOO AVE SE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49507-3780
Country : US
Telephone Number : 616-965-8390
Fax Number : 616-254-8192
Authorized Official
Title or Position : CEO
Name : TASHA BLACKMON
Credential :
Telephone Number : 616-965-8215
Provider Enumeration Date : 09/20/2011
Last Update Date : 08/25/2023

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1891887584 — PAULA R VANDERMEULEN LMSW
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1356420657 — PAMELA KAY HUFFMAN LLMSW
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1780739888 — CHERYL LYNN BAKER LMSW
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1457480436 — ANNETTE K KOLB LMSW
Practice Location Address:
2303 KALAMAZOO AVE SE
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Practice Fax: 616-233-0689

Directions to “CHERRY STREET SERVICES INC ” Practice Location

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