Healthcare Provider Details

I. General information

NPI: 1972270072
Provider Name (Legal Business Name): SAMANTHA LARSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 09/12/2021
Certification Date: 09/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 16TH ST W STE 31
BILLINGS MT
59102-4100
US

IV. Provider business mailing address

1026 CALENDULA CIR
BILLINGS MT
59105-2370
US

V. Phone/Fax

Practice location:
  • Phone: 406-274-7623
  • Fax:
Mailing address:
  • Phone: 406-208-6484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-50241
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: