Provider Demographics
NPI:1518210129
Name:NIXON, KASEY A
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:A
Last Name:NIXON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 E OCEAN BLVD
Mailing Address - Street 2:APT 14
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-2749
Mailing Address - Country:US
Mailing Address - Phone:406-202-3497
Mailing Address - Fax:
Practice Address - Street 1:2195 IRONWOOD CT STE D
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2624
Practice Address - Country:US
Practice Address - Phone:208-625-4887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ID6494101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator