Healthcare Provider Details

I. General information

NPI: 1346168614
Provider Name (Legal Business Name): LILY LAWSON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 COVENTRY LN
FORT WAYNE IN
46804-7145
US

IV. Provider business mailing address

5601 COVENTRY LN
FORT WAYNE IN
46804-7145
US

V. Phone/Fax

Practice location:
  • Phone: 260-459-6040
  • Fax:
Mailing address:
  • Phone: 260-459-6040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: