Provider Demographics
NPI:1073603163
Name:RUSSELL-MARTIN, LESLIE ANN (MS LMFT PHD LP)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ANN
Last Name:RUSSELL-MARTIN
Suffix:
Gender:F
Credentials:MS LMFT PHD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15920 233RD ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-5592
Mailing Address - Country:US
Mailing Address - Phone:320-632-5524
Mailing Address - Fax:888-991-2741
Practice Address - Street 1:16016 233RD ST
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-5583
Practice Address - Country:US
Practice Address - Phone:320-632-5524
Practice Address - Fax:888-991-2741
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4924103T00000X, 103G00000X
MNMN #1351106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN360040800Medicaid
MN730T3RUOtherBCBS OF MN PROVIDER NUMBE