Healthcare Provider Details

I. General information

NPI: 1881602571
Provider Name (Legal Business Name): SHAWN SOULE LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2416 E WASHINGTON ST STE A3
BLOOMINGTON IL
61704-1608
US

IV. Provider business mailing address

3019 BUFFALO LN
NORMAL IL
61761-7518
US

V. Phone/Fax

Practice location:
  • Phone: 309-825-2125
  • Fax:
Mailing address:
  • Phone: 309-825-2125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180003835
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: