Provider Demographics
NPI:1821376179
Name:COPELAND, KRYSTAL LYN (MSW)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LYN
Last Name:COPELAND
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 E LARNED ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-3905
Mailing Address - Country:US
Mailing Address - Phone:313-704-4837
Mailing Address - Fax:
Practice Address - Street 1:20303 KELLY RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48225-1206
Practice Address - Country:US
Practice Address - Phone:313-245-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MI680109634971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical