Healthcare Provider Details

I. General information

NPI: 1013824283
Provider Name (Legal Business Name): JOSHUA I SHANE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 W WILLOW KNOLLS DR
PEORIA IL
61614-1219
US

IV. Provider business mailing address

2101 W WILLOW KNOLLS DR
PEORIA IL
61614-1219
US

V. Phone/Fax

Practice location:
  • Phone: 309-282-3239
  • Fax: 309-693-8342
Mailing address:
  • Phone: 309-282-3239
  • Fax: 309-693-8342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.005449
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: