Provider Demographics
NPI:1215759832
Name:HEAVYRUNNER, LANDON RAY (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:LANDON
Middle Name:RAY
Last Name:HEAVYRUNNER
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 S 2ND ST W APT 3
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2386
Mailing Address - Country:US
Mailing Address - Phone:406-529-0913
Mailing Address - Fax:
Practice Address - Street 1:1511 S RUSSELL ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-3629
Practice Address - Country:US
Practice Address - Phone:406-829-9515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-729341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical