Healthcare Provider Details

I. General information

NPI: 1497240501
Provider Name (Legal Business Name): BRYAN MATTHEW LUTON LSW, LICDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2018
Last Update Date: 01/11/2025
Certification Date: 01/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24100 CHAGRIN BLVD STE 3300
BEACHWOOD OH
44122-5535
US

IV. Provider business mailing address

14020 PINE FOREST DR APT 208
NORTH ROYALTON OH
44133-5012
US

V. Phone/Fax

Practice location:
  • Phone: 800-642-4560
  • Fax: 888-391-5442
Mailing address:
  • Phone: 216-387-9797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.162721
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2411110
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: