Provider Demographics
NPI:1396559357
Name:POTTER, LELAND CHARLES (MSW)
Entity type:Individual
Prefix:
First Name:LELAND
Middle Name:CHARLES
Last Name:POTTER
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20090 POLK ST NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-2064
Mailing Address - Country:US
Mailing Address - Phone:218-531-9669
Mailing Address - Fax:855-761-1441
Practice Address - Street 1:20090 POLK ST NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-2064
Practice Address - Country:US
Practice Address - Phone:218-531-9669
Practice Address - Fax:855-761-1441
Is Sole Proprietor?:No
Enumeration Date:2025-02-01
Last Update Date:2025-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA674180300171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA674180300OtherMINNESOTA HEALTHCARE PROGRAMS - UMPI