=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972309987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLABORATIVE CARE CONSULTANTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2025
-----------------------------------------------------
Last Update Date | 07/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1057 GRAND AVE FL 2
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55105-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-384-1736
-----------------------------------------------------
Fax | 651-666-1507
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4734 WESTMINSTER CIR
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55122-2756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GRETCHEN MOEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-485-3923
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------