Healthcare Provider Details

I. General information

NPI: 1548766108
Provider Name (Legal Business Name): JANEL CULBERTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2338 W VAN WINKLE WAY
PEORIA IL
61615
US

IV. Provider business mailing address

411 HAMILTON BLVD STE 1908
PEORIA IL
61602-1146
US

V. Phone/Fax

Practice location:
  • Phone: 309-693-9189
  • Fax:
Mailing address:
  • Phone: 309-674-7874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501017339
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.023484
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: