Healthcare Provider Details

I. General information

NPI: 1780039693
Provider Name (Legal Business Name): KRYSTAL KIRK LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8090 PINEHURST ST
DETROIT MI
48204-3160
US

IV. Provider business mailing address

9329 TELEGRAPH RD
REDFORD MI
48239-1260
US

V. Phone/Fax

Practice location:
  • Phone: 313-717-7651
  • Fax:
Mailing address:
  • Phone: 313-850-6859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: