NPIMap

Organization Active NPI

Cherry Street Services Inc

Doing business as Southside Health Center

  • Federally Qualified Health Center (FQHC)
  • Grand Rapids, MI
National Provider Identifier
1386926004
Registry record updated Aug 25, 2023
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
Doing business as
Southside Health Center
Practice address
2303 Kalamazoo Ave SE
Grand Rapids, MI 49507-3780
Phone
(616) 965-8390
Fax
(616) 254-8192
NPI assigned
Sep 20, 2011
Last updated
Aug 25, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
CHERRY STREET SERVICES INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 25, 2023

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

Authorized official

Name
Tasha Blackmon
Title
Ceo
Phone
(616) 965-8215

Specialties & licenses 8

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) Counselor 101YA0400X NU
Mental Health Counselor 101YM0800X NU
Addiction (Substance Use Disorder) Psychologist 103TA0400X NU
Clinical Psychologist 103TC0700X NU
Clinical Social Worker 1041C0700X NU
Registered Nurse 163W00000X NU
Addiction Medicine (Anesthesiology) Physician 207LA0401X NU
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

2303 Kalamazoo Ave SE
Grand Rapids, MI 49507-3780

Mailing address

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

Other names 1

  • Southside Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI3 enrollments
Opioid treatment program
Medicare-enrolled since Mar 1, 2020

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20040804000274 MI Part B Supplier - Clinic/Group Practice 6800707647 Receives reassigned benefits from 133 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Grand Rapids, MI
O20120313000985 MI Part A Provider - Federally Qualified Health Center (FQHC) 6800707647 Practice locations: Grand Rapids, MI
O20200409000139 MI Part B Supplier - Opioid Treatment Program (Otp) 6800707647 1 other NPI on this enrollment
Practice locations: Grand Rapids, MI; Muskegon, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1386926004. Details of each certification follow.

Federally qualified health center certification: CCN 231970

Legal name
CHERRY STREET SERVICES INC
Doing business as
SOUTHSIDE HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 3, 2012
Last certification
May 3, 2012
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 1, 1988 in MI
Enrollment address
2303 Kalamazoo Ave SE
Grand Rapids, MI 49507-3780

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

Other NPIs on the same Medicare enrollment 14

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 14

National Provider Directory

National Provider Directory
Part of
Employee Assistance Center Fulton

Ownership & related parties

All disclosed owners & managing parties 17

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 1%
Allen Tenhoor Individual Corporate OfficerBoard Member Oct 1, 2011
Ziyadah Shakir Individual Corporate OfficerBoard Member Oct 1, 2011
Allison Swets Individual Corporate OfficerBoard Member Oct 1, 2011
Esperanza Degnan Individual Corporate DirectorBoard Member Dec 28, 2021
Richard Stevens Individual Corporate DirectorBoard Member Dec 28, 2021
Tasha Blackmon Individual Corporate OfficerCeo Dec 28, 2021
W-2 Managing EmployeeCeo Dec 28, 2021
Margaret McGuiness Individual Corporate DirectorBoard Member Apr 1, 2013 1%
David Smith Individual Corporate OfficerBoard Member Oct 1, 2011
Barbara Wybrecht Individual Corporate DirectorBoard Member Sep 8, 2016 1%
Gwynn Bult Individual Corporate DirectorBoard Member Apr 25, 2023
Evelyn Esparza-Gonzales Individual Corporate DirectorBoard Member Apr 25, 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 25, 2023
Scott David Alfree Individual Corporate DirectorBoard Member Mar 1, 2013 1%
Carol Dickinson Individual Corporate DirectorBoard Member Apr 1, 2013 1%

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": "1316476800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1692921600000",
    "number": "1386926004",
    "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": "2303 KALAMAZOO AVE SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495073780",
            "telephone_number": "616-965-8390",
            "fax_number": "616-254-8192"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHERRY STREET SERVICES INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CHERRY STREET SERVICES INC",
        "enumeration_date": "2011-09-20",
        "last_updated": "2023-08-25",
        "certification_date": "2023-08-25",
        "status": "A",
        "authorized_official_last_name": "BLACKMON",
        "authorized_official_first_name": "TASHA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "616-965-8215"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "103TA0400X",
            "taxonomy_group": "",
            "desc": "Psychologist, Addiction (Substance Use Disorder)",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207LA0401X",
            "taxonomy_group": "",
            "desc": "Anesthesiology, Addiction Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southside Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Southside Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grand Rapids, MI

Sources for this page

Verify at the official NPI Registry.