Provider Demographics
NPI:1831722594
Name:COLLABORATION FOR PSYCHOLOGICAL WELLNESS, LLC
Entity type:Organization
Organization Name:COLLABORATION FOR PSYCHOLOGICAL WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:DINESH
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:612-276-2462
Mailing Address - Street 1:12000 PORTLAND AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4469
Mailing Address - Country:US
Mailing Address - Phone:612-276-2462
Mailing Address - Fax:612-246-3682
Practice Address - Street 1:12000 PORTLAND AVE STE 120
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4469
Practice Address - Country:US
Practice Address - Phone:612-276-2462
Practice Address - Fax:612-246-3682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty