Healthcare Provider Details

I. General information

NPI: 1699525857
Provider Name (Legal Business Name): COLLABORATIVE PSYCHIATRIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2024
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5995 OREN AVE N STE 203
OAK PARK HEIGHTS MN
55082-6379
US

IV. Provider business mailing address

1406 HILLTOP RDG
HOULTON WI
54082-2013
US

V. Phone/Fax

Practice location:
  • Phone: 651-504-5103
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN GERSTNER
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 651-504-5103