Healthcare Provider Details

I. General information

NPI: 1972439925
Provider Name (Legal Business Name): MELISSA LARSEN LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 SHOSHONE ST E
TWIN FALLS ID
83301-6111
US

IV. Provider business mailing address

3506 E 3290 N
KIMBERLY ID
83341-5332
US

V. Phone/Fax

Practice location:
  • Phone: 208-829-9441
  • Fax:
Mailing address:
  • Phone: 208-829-9441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MELISSA LARSEN
Title or Position: CLINICIAN
Credential: LCSW
Phone: 208-829-9441