=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497240501
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN MATTHEW LUTON LSW, LICDC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2018
-----------------------------------------------------
Last Update Date | 01/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24100 CHAGRIN BLVD STE 3300
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122-5535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-642-4560
-----------------------------------------------------
Fax | 888-391-5442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14020 PINE FOREST DR APT 208
-----------------------------------------------------
City | NORTH ROYALTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44133-5012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-387-9797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | S.2411110
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LICDC.162721
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------