Provider Demographics
NPI:1699343111
Name:LAWLESS, JOHN KENNETH (LMT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KENNETH
Last Name:LAWLESS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1374
Mailing Address - Country:US
Mailing Address - Phone:517-526-4967
Mailing Address - Fax:
Practice Address - Street 1:2045 ASHER CT
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8444
Practice Address - Country:US
Practice Address - Phone:517-526-4967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501002159225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist