Provider Demographics
NPI:1609203108
Name:LEEDER-MARTINEZ, LAURA M (LSAA)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:M
Last Name:LEEDER-MARTINEZ
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N THORNTON ST STE J
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-5508
Mailing Address - Country:US
Mailing Address - Phone:575-935-8522
Mailing Address - Fax:575-935-8524
Practice Address - Street 1:1200 N THORNTON ST STE J
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5508
Practice Address - Country:US
Practice Address - Phone:575-935-8522
Practice Address - Fax:575-935-8524
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0148831101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)