Healthcare Provider Details

I. General information

NPI: 1649194994
Provider Name (Legal Business Name): THE MISSING PEACE COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2026
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4159 PENN AVE N
MINNEAPOLIS MN
55412-1535
US

IV. Provider business mailing address

4159 PENN AVE N
MINNEAPOLIS MN
55412-1535
US

V. Phone/Fax

Practice location:
  • Phone: 612-412-7811
  • Fax:
Mailing address:
  • Phone: 612-412-7811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. CICERO DESHAWN TAYLOR
Title or Position: CHIEF OF COMMUNITY OUTREACH
Credential:
Phone: 612-412-7811