Provider Demographics
NPI:1023887841
Name:LARSON, KEYAWNA JANICE (SWLC)
Entity type:Individual
Prefix:
First Name:KEYAWNA
Middle Name:JANICE
Last Name:LARSON
Suffix:
Gender:F
Credentials:SWLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 PHEASANT DR
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2440
Mailing Address - Country:US
Mailing Address - Phone:406-407-4513
Mailing Address - Fax:
Practice Address - Street 1:38 E WASHINGTON ST STE 3
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3974
Practice Address - Country:US
Practice Address - Phone:406-407-4513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-20
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-SWLC-LIC-68438104100000X
MTBBH-ACLC-LIC-78632101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker