Healthcare Provider Details

I. General information

NPI: 1639647233
Provider Name (Legal Business Name): KATHY LYNN SHAPLEY PH.D. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W BRADLEY AVE
PEORIA IL
61625-0003
US

IV. Provider business mailing address

1501 W BRADLEY AVE
PEORIA IL
61625-0003
US

V. Phone/Fax

Practice location:
  • Phone: 210-379-9162
  • Fax:
Mailing address:
  • Phone: 210-379-9162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2600551
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number112159
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146017029
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: