Provider Demographics
NPI:1366711418
Name:NICHOLSON, KASEY JOSEPH (MS, LAC)
Entity type:Individual
Prefix:MR
First Name:KASEY
Middle Name:JOSEPH
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7931
Mailing Address - Country:US
Mailing Address - Phone:406-829-9515
Mailing Address - Fax:406-829-9519
Practice Address - Street 1:830 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7931
Practice Address - Country:US
Practice Address - Phone:406-829-9515
Practice Address - Fax:406-829-9519
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1340 LAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)