Basic Information
| Provider Information | |||||||||
| NPI: | 1003292277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRICKEY | ||||||||
| FirstName: | KASEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AU.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARTINEZ | ||||||||
| OtherFirstName: | KASEY | ||||||||
| OtherMiddleName: | AMANDA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4907 | ||||||||
| Address2: | 700 WEST KENT AVENUE | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598064907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065413277 | ||||||||
| FaxNumber: | 4065413811 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W KENT AVE | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598016772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065413277 | ||||||||
| FaxNumber: | 4065413811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2015 | ||||||||
| LastUpdateDate: | 06/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | Y | Speech, Language and Hearing Service Providers | Audiologist | 332S00000X | MT | N | Suppliers | Hearing Aid Equipment |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | MT | MEDICAID |