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NPI Code Detail

MEDICARE: DIANE DEBRA LEADERS MSW, LICSW

MEDICARE: DIANE DEBRA LEADERS MSW, LICSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker14409MN

General Provider Information

NPI Number : 1366196115
Entity Type Code : Individual
Provider Name (Legal Business Name) : DIANE DEBRA LEADERS MSW, LICSW
Provider Business Mailing Address
First Line : 516 S POKEGAMA AVE
Second Line :
City : GRAND RAPIDS
State : MN
Zip : 55744-3820
Country : US
Telephone Number : 218-327-2001
Fax Number :
Provider Business Practice Location Address
First Line : 516 S POKEGAMA AVE
Second Line :
City : GRAND RAPIDS
State : MN
Zip : 55744-3820
Country : US
Telephone Number : 218-327-2001
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/10/2022
Last Update Date : 02/10/2022

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