Provider Demographics
NPI:1417456401
Name:SHUSTER, BRENT KEELER (ACMHC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:KEELER
Last Name:SHUSTER
Suffix:
Gender:M
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E 5600 S STE 304
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8174
Mailing Address - Country:US
Mailing Address - Phone:801-210-9443
Mailing Address - Fax:
Practice Address - Street 1:3556 S 5600 W # 1-472
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2815
Practice Address - Country:US
Practice Address - Phone:801-210-9443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11226387-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health