MEDICARE: CRYSTAL KIM COPELAND LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	109837-01	NY

General Provider Information

NPI Number	:	1558020461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL KIM COPELAND LMSW

Provider Business Mailing Address
First Line	:	1026 ONTARIO ST
Second Line	:
City	:	UTICA
State	:	NY
Zip	:	13501-2744
Country	:	US
Telephone Number	:	315-570-5187
Fax Number	:

Provider Business Practice Location Address
First Line	:	8658 AITKEN AVE
Second Line	:
City	:	WHITESBORO
State	:	NY
Zip	:	13492-2609
Country	:	US
Telephone Number	:	315-570-5187
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2021
Last Update Date	:	12/08/2021

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