Healthcare Provider Details

I. General information

NPI: 1437067329
Provider Name (Legal Business Name): SHANE STUFFLEBEAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5009 N GLEN PARK PLACE RD
PEORIA IL
61614-4677
US

IV. Provider business mailing address

5009 N GLEN PARK PLACE RD
PEORIA IL
61614-4677
US

V. Phone/Fax

Practice location:
  • Phone: 309-683-8170
  • Fax:
Mailing address:
  • Phone: 309-683-8170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.040935
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: