Healthcare Provider Details

I. General information

NPI: 1174458376
Provider Name (Legal Business Name): SHANNON MARIE PENDLAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 LIBERTY AVE
NEWTON IL
62448-1808
US

IV. Provider business mailing address

605 S VAN BUREN ST
NEWTON IL
62448-1651
US

V. Phone/Fax

Practice location:
  • Phone: 618-783-7529
  • Fax:
Mailing address:
  • Phone: 618-783-7529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-505714
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: