Provider Demographics
NPI:1356000772
Name:MARTIN, LEANNE MARIE
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21400 SYLVAN CT
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:IN
Mailing Address - Zip Code:46507-9321
Mailing Address - Country:US
Mailing Address - Phone:574-596-2935
Mailing Address - Fax:
Practice Address - Street 1:6910 N MAIN ST UNIT 4
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-9681
Practice Address - Country:US
Practice Address - Phone:574-931-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health