Provider Demographics
NPI:1275823742
Name:LEECH LAKE BAND OF OJIBWE
Entity Type:Organization
Organization Name:LEECH LAKE BAND OF OJIBWE
Other - Org Name:LEECH LAKE BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEECH LAKE HUMAN SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-335-8295
Mailing Address - Street 1:115 6TH STREET NW, STE. E
Mailing Address - Street 2:
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633
Mailing Address - Country:US
Mailing Address - Phone:218-335-3050
Mailing Address - Fax:218-335-4410
Practice Address - Street 1:16123 GRANT UTLEY AVE NW
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633
Practice Address - Country:US
Practice Address - Phone:218-335-3050
Practice Address - Fax:218-335-4410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19439251S00000X
MN261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251S00000XAgenciesCommunity/Behavioral Health