Healthcare Provider Details

I. General information

NPI: 1821376179
Provider Name (Legal Business Name): KRYSTAL LYN COPELAND MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 02/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20303 KELLY RD
DETROIT MI
48225-1206
US

IV. Provider business mailing address

2919 E LARNED ST
DETROIT MI
48207-3905
US

V. Phone/Fax

Practice location:
  • Phone: 313-245-7000
  • Fax:
Mailing address:
  • Phone: 313-704-4837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number68010963497
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: