Healthcare Provider Details

I. General information

NPI: 1548822943
Provider Name (Legal Business Name): HEALTH AND WELLNESS COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 LONG LAKE RD STE 160
NEW BRIGHTON MN
55112-6414
US

IV. Provider business mailing address

900 LONG LAKE RD STE 160
NEW BRIGHTON MN
55112-6414
US

V. Phone/Fax

Practice location:
  • Phone: 612-706-9630
  • Fax: 612-706-9617
Mailing address:
  • Phone: 612-706-9630
  • Fax: 612-706-9617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code364SP0813X
TaxonomyGeropsychiatric Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD EARL HOBBS
Title or Position: DIRECTOR OF OPERATIONS
Credential: LMFT
Phone: 651-338-6289