Healthcare Provider Details

I. General information

NPI: 1215759832
Provider Name (Legal Business Name): LANDON RAY HEAVYRUNNER MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2024
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 S RUSSELL ST
MISSOULA MT
59801-3629
US

IV. Provider business mailing address

1309 S 2ND ST W APT 3
MISSOULA MT
59801-2386
US

V. Phone/Fax

Practice location:
  • Phone: 406-829-9515
  • Fax:
Mailing address:
  • Phone: 406-529-0913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-72934
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: