{
"Npi": {
"NPI": "1972309987",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "COLLABORATIVE CARE CONSULTANTS LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "4734 WESTMINSTER CIR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "EAGAN",
"MailingAddressStateName": "MN",
"MailingAddressPostalCode": "55122-2756",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": null,
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1057 GRAND AVE FL 2",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SAINT PAUL",
"PracticeLocationAddressStateName": "MN",
"PracticeLocationAddressPostalCode": "55105-3002",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "651-384-1736",
"PracticeLocationAddressFaxNumber": "651-666-1507",
"EnumerationDate": "02/20/2025",
"LastUpdateDate": "07/18/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MOEN",
"AuthorizedOfficialFirstName": "GRETCHEN",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "651-485-3923",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "363LP0200X",
"TaxonomyName": "Pediatric Nurse Practitioner",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}