Provider Demographics
NPI:1619635273
Name:COPELAND, CRYSTAL GILLETTE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:GILLETTE
Last Name:COPELAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 GEORGETOWN LN
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6818
Mailing Address - Country:US
Mailing Address - Phone:850-461-8340
Mailing Address - Fax:
Practice Address - Street 1:2514 GEORGETOWN LN
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6818
Practice Address - Country:US
Practice Address - Phone:850-461-8340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2023-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH20777101YM0800X
FLMH22502101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty