Healthcare Provider Details

I. General information

NPI: 1366711418
Provider Name (Legal Business Name): KASEY JOSEPH NICHOLSON M.S., LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 W CENTRAL AVE
MISSOULA MT
59801-7931
US

IV. Provider business mailing address

830 W CENTRAL AVE
MISSOULA MT
59801-7931
US

V. Phone/Fax

Practice location:
  • Phone: 406-829-9515
  • Fax: 406-829-9519
Mailing address:
  • Phone: 406-829-9515
  • Fax: 406-829-9519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1340 LAC
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: