Healthcare Provider Details

I. General information

NPI: 1972309987
Provider Name (Legal Business Name): COLLABORATIVE CARE CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 GRAND AVE FL 2
SAINT PAUL MN
55105-3002
US

IV. Provider business mailing address

4734 WESTMINSTER CIR
EAGAN MN
55122-2756
US

V. Phone/Fax

Practice location:
  • Phone: 651-384-1736
  • Fax: 651-666-1507
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GRETCHEN MOEN
Title or Position: OWNER
Credential:
Phone: 651-485-3923