Provider Demographics
NPI:1891109617
Name:LARSEN, MELODY (LMFT, LCPC)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:LMFT, LCPC
Other - Prefix:
Other - First Name:MELODY
Other - Middle Name:
Other - Last Name:BRENNEISEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:2126 S 12TH ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4814
Mailing Address - Country:US
Mailing Address - Phone:605-641-7618
Mailing Address - Fax:
Practice Address - Street 1:3819 STEPHENS AVE STE 300
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-215-2225
Practice Address - Fax:406-215-2226
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LMFT-LIC-38685106H00000X
MTBBH-LCPC-LIC-38841101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist