Healthcare Provider Details

I. General information

NPI: 1023887841
Provider Name (Legal Business Name): KEYAWNA JANICE LARSON SWLC, ACLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 12/21/2025
Certification Date: 12/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MERIDIAN CT APT A201
KALISPELL MT
59901-4284
US

IV. Provider business mailing address

41 MERIDIAN CT APT A201
KALISPELL MT
59901-4284
US

V. Phone/Fax

Practice location:
  • Phone: 406-407-4513
  • Fax:
Mailing address:
  • Phone: 406-407-4513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-ACLC-LIC-78632
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberBBH-SWLC-LIC-68438
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: