NPIMap

Organization Active NPI

Pine Rest Christian Mental Heatth Services

  • Psychiatry Physician
  • Grand Rapids, MI
National Provider Identifier
1508875667
Registry record updated Nov 4, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
PINE REST CHRISTIAN MENTAL HEATTH SERVICES
Practice address
310 Lafayette Ave SE
Grand Rapids, MI 49503-4693
Phone
(616) 913-1400
NPI assigned
Aug 7, 2006
Last updated
Nov 4, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
PINE REST CHRISTIAN MENTAL HEALTH SERVICESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 4, 2020

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

Authorized official

Name
Diane Fennema
Title
Managed Care Administrator
Phone
(616) 281-6372

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X NU
Nurse Practitioner 363L00000X NU
Psychologist 103T00000X NU
Social Worker 104100000X NU
Psychiatry Physician 2084P0800X NU Primary

Addresses

Primary practice location

310 Lafayette Ave SE
Grand Rapids, MI 49503-4693

Mailing address

300 68TH St SE
Grand Rapids, MI 49548-6927
Phone (616) 455-5000

Other identifiers 5

IdentifierTypeStateIssuer
260D17625OtherMIPSYCHIATRISTS
500D11133OtherMINURSE PRACT.
680D16189OtherMIPSYCHOLOGISTS
800D16222OtherMISOCIAL WORKERS
P10D11275OtherMIPSYCHOLGOGISTS-MA, DOCTOR

National Provider Directory

National Provider Directory
Tax ID family
Pine Rest CHR M H S42 organizations share this tax ID, including this one
Part of
Pine Rest CHR M H S

Other organizations with this tax ID 41

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

View all 41

NPI Registry JSON

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

{
    "created_epoch": "1154908800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1604448000000",
    "number": "1508875667",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 68TH ST SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495486927",
            "telephone_number": "616-455-5000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "310 LAFAYETTE AVE SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495034693",
            "telephone_number": "616-913-1400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PINE REST CHRISTIAN MENTAL HEATTH SERVICES",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PINE REST CHRISTIAN MENTAL HEALTH SERVICES",
        "enumeration_date": "2006-08-07",
        "last_updated": "2020-11-04",
        "certification_date": "2020-11-04",
        "status": "A",
        "authorized_official_last_name": "FENNEMA",
        "authorized_official_first_name": "DIANE",
        "authorized_official_title_or_position": "MANAGED CARE ADMINISTRATOR",
        "authorized_official_telephone_number": "616-281-6372"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PSYCHIATRISTS",
            "identifier": "260D17625",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NURSE PRACT.",
            "identifier": "500D11133",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PSYCHOLOGISTS",
            "identifier": "680D16189",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SOCIAL WORKERS",
            "identifier": "800D16222",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PSYCHOLGOGISTS-MA, DOCTOR",
            "identifier": "P10D11275",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Rapids, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 4, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.