Provider Demographics
NPI:1003855743
Name:MARTIN, LELAND KARL (PHD)
Entity Type:Individual
Prefix:DR
First Name:LELAND
Middle Name:KARL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2434 COMMERCE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1480
Mailing Address - Country:US
Mailing Address - Phone:952-595-0562
Mailing Address - Fax:952-595-0564
Practice Address - Street 1:2434 COMMERCE BLVD STE A
Practice Address - Street 2:
Practice Address - City:MOUND
Practice Address - State:MN
Practice Address - Zip Code:55364-1480
Practice Address - Country:US
Practice Address - Phone:952-595-0562
Practice Address - Fax:952-595-0564
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3095103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN783725900Medicaid
MNHP27418OtherHEALTH PARTNERS
MN6129689OtherUNITED BEHAVIORAL HEALTH
MN169220OtherCOMPSYCH
MN5H813MAOtherBLUE CROSS BLUE SHIELD
MN109951OtherBEHAVIORAL HEALTH CARE PR