Provider Demographics
NPI:1780039693
Name:KIRK, KRYSTAL (LLMSW)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:KIRK
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9329 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1260
Mailing Address - Country:US
Mailing Address - Phone:313-850-6859
Mailing Address - Fax:
Practice Address - Street 1:8090 PINEHURST ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-3160
Practice Address - Country:US
Practice Address - Phone:313-717-7651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health