Provider Demographics
NPI:1073821708
Name:LUSTER, SHANNON RICHARD (BA)
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:RICHARD
Last Name:LUSTER
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60863
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99706-0863
Mailing Address - Country:US
Mailing Address - Phone:907-474-4908
Mailing Address - Fax:
Practice Address - Street 1:3830 S CUSHMAN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7530
Practice Address - Country:US
Practice Address - Phone:907-452-1575
Practice Address - Fax:907-455-1460
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health