Provider Demographics
NPI:1912187923
Name:PRUSSIA, LEAH (LICSW)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:PRUSSIA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 2ND ST SW
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1417
Mailing Address - Country:US
Mailing Address - Phone:218-631-1714
Mailing Address - Fax:
Practice Address - Street 1:11 2ND ST SW
Practice Address - Street 2:SUITE 1
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1417
Practice Address - Country:US
Practice Address - Phone:218-631-1714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN143391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical