MEDICARE: KEYAWNA JANICE LARSON SWLC, ACLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	BBH-ACLC-LIC-78632	MT
2	104100000X	Social Worker	BBH-SWLC-LIC-68438	MT

General Provider Information

NPI Number	:	1023887841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEYAWNA JANICE LARSON SWLC, ACLC

Provider Business Mailing Address
First Line	:	41 MERIDIAN CT APT A201
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-4284
Country	:	US
Telephone Number	:	406-407-4513
Fax Number	:

Provider Business Practice Location Address
First Line	:	41 MERIDIAN CT APT A201
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-4284
Country	:	US
Telephone Number	:	406-407-4513
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2023
Last Update Date	:	12/21/2025

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