Provider Demographics
NPI:1336676451
Name:POTTS, LEILA LISSETTE (MS, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:LEILA
Middle Name:LISSETTE
Last Name:POTTS
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:LEILA
Other - Middle Name:LISSETTE
Other - Last Name:SALAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5528 FRONTIER DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-1818
Mailing Address - Country:US
Mailing Address - Phone:850-586-0074
Mailing Address - Fax:
Practice Address - Street 1:171 STATE HIGHWAY 83 UNIT A110
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-7427
Practice Address - Country:US
Practice Address - Phone:850-585-9189
Practice Address - Fax:850-951-0898
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-52177103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020921600Medicaid