| Organization Name: | LEECH LAKE OUTPATIENT TREATMENT PROGRAM |
| NPI Number: | 1275701666 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | GLORIA MELLADO (A & D PROGRAM DIRECTOR) |
| Mailing Address: | 6095 161st Ave Nw Cass Lake |
| State: | MN US |
| Postal Code: | 566333428 |
| Phone Number: | 2183358308 |
| Fax Number: | 2183358307 |
| NPI Enumeration Date: | 02/19/2008 |
| NPI Last Update Date: | 07/18/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |