Provider Demographics
NPI:1275663114
Name:SHANE, IDELLE BUTLER (MSW BCD LCSW)
Entity Type:Individual
Prefix:
First Name:IDELLE
Middle Name:BUTLER
Last Name:SHANE
Suffix:
Gender:F
Credentials:MSW BCD LCSW
Other - Prefix:
Other - First Name:IDELLE
Other - Middle Name:
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCD
Mailing Address - Street 1:311 E. MAIN ST. STE.604
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-4855
Mailing Address - Country:US
Mailing Address - Phone:309-342-2727
Mailing Address - Fax:
Practice Address - Street 1:311 E MAIN ST STE 604
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-4882
Practice Address - Country:US
Practice Address - Phone:309-341-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL002425OtherBOARD CERT DIPLOMATE