Provider Demographics
NPI:1417306861
Name:BOYDSTON, TYRELL LAMAR (LMSW)
Entity type:Individual
Prefix:
First Name:TYRELL
Middle Name:LAMAR
Last Name:BOYDSTON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15095 ROSEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2342
Mailing Address - Country:US
Mailing Address - Phone:313-695-1472
Mailing Address - Fax:
Practice Address - Street 1:30150 TELEGRAPH RD STE 245
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4521
Practice Address - Country:US
Practice Address - Phone:800-693-1916
Practice Address - Fax:248-605-3525
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MI6801108524104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical