Healthcare Provider Details

I. General information

NPI: 1467163378
Provider Name (Legal Business Name): MELISSA LARSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2022
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 MAIN AVE W STE 500
TWIN FALLS ID
83301-6580
US

IV. Provider business mailing address

133 MAIN AVE W STE 500
TWIN FALLS ID
83301-6580
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 Code1041C0700X
TaxonomyClinical Social Worker
License Number8911288
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: