Provider Demographics
NPI:1962978205
Name:LAWTON, ETHAN CHARLES
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:CHARLES
Last Name:LAWTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7760 S M 52
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-9265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1040 W BRISTOL RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-5516
Practice Address - Country:US
Practice Address - Phone:810-257-3705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-14
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIXYU993053471Medicaid