MEDICARE: KRYSTAL KIRK LLMSW

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1041C0700X	Clinical Social Worker
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center
3	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1780039693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL KIRK LLMSW

Provider Business Mailing Address
First Line	:	9329 TELEGRAPH RD
Second Line	:
City	:	REDFORD
State	:	MI
Zip	:	48239-1260
Country	:	US
Telephone Number	:	313-850-6859
Fax Number	:

Provider Business Practice Location Address
First Line	:	8090 PINEHURST ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48204-3160
Country	:	US
Telephone Number	:	313-717-7651
Fax Number	:

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

Provider Enumeration Date	:	04/28/2016
Last Update Date	:	12/23/2019

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Directions to “ KRYSTAL KIRK LLMSW” Practice Location

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