NPIMap

Organization Active NPI

Cherry Street Services Inc

  • Federally Qualified Health Center (FQHC)
  • Wyoming, MI
National Provider Identifier
1184974263
Registry record updated May 17, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CHERRY STREET SERVICES INC
Practice address
2929 Burlingame Ave SW
Wyoming, MI 49509-2609
Phone
(616) 965-8333
Fax
(616) 940-5820
NPI assigned
Sep 14, 2012
Organization subpart
Yes
Parent organization
CHERRY STREET SERVICESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 17, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Tasha Blackmon
Title
Ceo
Phone
(616) 965-8200

Specialties & licenses 14

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X
Cognitive & Behavioral PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TB0200X
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X
Group Psychotherapy PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TP2701X
Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 104100000X
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X
Registered DietitianGroup: 193200000X MULTI-SPECIALTY GROUP 133V00000X
Optometrist 152W00000X
OpticianGroup: 193200000X MULTI-SPECIALTY GROUP 156FX1800X
Registered NurseGroup: 193200000X MULTI-SPECIALTY GROUP 163W00000X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

2929 Burlingame Ave SW
Wyoming, MI 49509-2609

Mailing address

100 Cherry St SE
Grand Rapids, MI 49503-4526
Phone (616) 965-8200

Other names 1

  • Wyoming Community Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20121023000498 MI Part A Provider - Federally Qualified Health Center (FQHC) 6800707647 Practice locations: Wyoming, MI

Federally qualified health center certification: CCN 231986

Legal name
CHERRY STREET SERVICES INC
Doing business as
WYOMING COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 16, 2012
Last certification
Nov 16, 2012
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 1, 1988 in MI
Enrollment address
2929 Burlingame Ave SW
Wyoming, MI 49509-2600

Other NPIs with the same Medicare PAC ID 19

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 19

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
23D2047786Wyoming Community Health Center2929 Burlingame Avenue S W, Wyoming, MI 49509Provider-performed microscopyJun 25, 2027

National Provider Directory

National Provider Directory
Tax ID family
Employee Assistance Center Fulton29 organizations share this tax ID, including this one
Part of
Employee Assistance Center Fulton

Other organizations with this tax ID 28

Organizations that report the same tax identification number in the National Provider Directory.

View all 28

Ownership & related parties

All disclosed owners & managing parties 16

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Elizabeth Triezenberg Individual Corporate DirectorBoard Member Sep 8, 2016
Allen Tenhoor Individual Corporate DirectorBoard Member Apr 21, 2023
Ziyadah Shakir Individual Corporate OfficerBoard Member Oct 1, 2011
Allison Swets Individual Corporate DirectorBoard Member Apr 21, 2023
Esperanza Degnan Individual Corporate DirectorBoard Member Dec 28, 2021
Richard Stevens Individual Corporate DirectorBoard Member Apr 21, 2023
Tasha Blackmon Individual Corporate OfficerCeo Dec 28, 2021
W-2 Managing EmployeeCeo Dec 28, 2021
Margaret McGuiness Individual Corporate DirectorBoard Member Apr 1, 2013
David Smith Individual Corporate OfficerBoard Member Oct 1, 2011
Barbara Wybrecht Individual Corporate DirectorBoard Member Sep 8, 2016
Gwynn Bult Individual Corporate DirectorBoard Member Apr 21, 2023
Evelyn Esparza-Gonzales Individual Corporate DirectorBoard Member Apr 21, 2023
Francena Purchase-Owens Individual Corporate DirectorBoard Member Dec 28, 2021
Kimberly Lavender Individual Corporate OfficerBoard Member Oct 1, 2011
Leslie King Individual Corporate DirectorBoard Member Apr 21, 2023
Scott David Alfree Individual Corporate DirectorBoard Member Mar 1, 2013

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Barry Community Health CenterHastings, MI, CCN 231122 Federally qualified health center Operational/Managerial Control Dec 1, 2017

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1347580800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1715904000000",
    "number": "1184974263",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 CHERRY ST SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495034526",
            "telephone_number": "616-965-8200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2929 BURLINGAME AVE SW",
            "city": "WYOMING",
            "state": "MI",
            "postal_code": "495092609",
            "telephone_number": "616-965-8333",
            "fax_number": "616-940-5820"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHERRY STREET SERVICES INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CHERRY STREET SERVICES",
        "enumeration_date": "2012-09-14",
        "last_updated": "2024-05-17",
        "certification_date": "2024-05-17",
        "status": "A",
        "authorized_official_last_name": "BLACKMON",
        "authorized_official_first_name": "TASHA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "616-965-8200",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TB0200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Cognitive & Behavioral",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TP2701X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Group Psychotherapy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "133V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dietitian, Registered",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "156FX1800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Technician/Technologist, Optician",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Registered Nurse",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Wyoming Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Wyoming Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wyoming, MI

Sources for this page

Verify at the official NPI Registry.