MEDICARE: PINE REST CHRISTIAN MENTAL HEALTH SERVICES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103T00000X	Psychologist
2	104100000X	Social Worker
3	363A00000X	Physician Assistant
4	363L00000X	Nurse Practitioner
5	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	500D11133	OTHER	MI	NURSE PRACTIONERS
2	680D16189	OTHER	MI	PSYCHOLOGISTS
3	800D16222	OTHER	MI	SOCIAL WORKERS
4	350D148360	OTHER	MI	PEDIATRICS
5	110D148370	OTHER	MI	INTERNAL MD
6	260D17625	OTHER	MI	PSYCHIATRIST
7	P10D11275	OTHER	MI	PSYCHOLOGISTS, MA, DOCTOR

General Provider Information

NPI Number	:	1619987740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE REST CHRISTIAN MENTAL HEALTH SERVICES

Provider Business Mailing Address
First Line	:	300 68TH ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49548-6927
Country	:	US
Telephone Number	:	616-455-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	9090 S RODGERS CT SE
Second Line	:
City	:	CALEDONIA
State	:	MI
Zip	:	49316-8052
Country	:	US
Telephone Number	:	616-891-8770
Fax Number	:

Authorized Official
Title or Position	:	MANAGED CARE ADMINISTRATOR
Name	:	DIANE FENNEMA
Credential	:
Telephone Number	:	616-281-6372

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	11/04/2020

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