Provider Demographics
NPI:1316757693
Name:BUSSE, SHANNON (ACMHC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BUSSE
Suffix:
Gender:F
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982 E 1350 S APT G301
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-2670
Mailing Address - Country:US
Mailing Address - Phone:773-865-6866
Mailing Address - Fax:
Practice Address - Street 1:512 W 750 S STE A
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84010-7221
Practice Address - Country:US
Practice Address - Phone:801-935-8449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1419178-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health