Provider Demographics
NPI:1497240501
Name:LUTON, BRYAN MATTHEW (LSW, LICDC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:MATTHEW
Last Name:LUTON
Suffix:
Gender:M
Credentials:LSW, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14020 PINE FOREST DR APT 208
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-5012
Mailing Address - Country:US
Mailing Address - Phone:216-387-9797
Mailing Address - Fax:
Practice Address - Street 1:24100 CHAGRIN BLVD STE 3300
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5535
Practice Address - Country:US
Practice Address - Phone:800-642-4560
Practice Address - Fax:888-391-5442
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-30
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2411110104100000X
OHLICDC.162721101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0413873Medicaid