Healthcare Provider Details

I. General information

NPI: 1518210129
Provider Name (Legal Business Name): KASEY A NIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 IRONWOOD CT STE D
COEUR D ALENE ID
83814-2624
US

IV. Provider business mailing address

3700 E OCEAN BLVD APT 14
LONG BEACH CA
90803-2749
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-4887
  • Fax:
Mailing address:
  • Phone: 406-202-3497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6494
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: