MEDICARE: CHEYENNE CORPRON SWLC, LAC

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	101YM0800X	Mental Health Counselor	BBH-SWLC-LIC-71187	MT
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	BBH-LAC-LIC-37003	MT

General Provider Information

NPI Number	:	1457815359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHEYENNE CORPRON SWLC, LAC

Provider Business Mailing Address
First Line	:	30 2ND ST E STE B28
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-4563
Country	:	US
Telephone Number	:	406-270-6265
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 2ND ST E STE B28
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-4563
Country	:	US
Telephone Number	:	406-270-6265
Fax Number	:

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

Provider Enumeration Date	:	01/24/2019
Last Update Date	:	02/03/2026

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