Provider Demographics
NPI:1417306861
Name:BOYDSTON, TYRELL LAMAR (MSW)
Entity Type:Individual
Prefix:
First Name:TYRELL
Middle Name:LAMAR
Last Name:BOYDSTON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 WOODVIEW DR
Mailing Address - Street 2:362
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-6813
Mailing Address - Country:US
Mailing Address - Phone:313-695-1472
Mailing Address - Fax:
Practice Address - Street 1:18316 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-5007
Practice Address - Country:US
Practice Address - Phone:248-615-9730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical