Healthcare Provider Details

I. General information

NPI: 1639553142
Provider Name (Legal Business Name): BIANCA ROE OTD, OTR/L, RDN, CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3709 N KEDZIE AVE
CHICAGO IL
60618-4503
US

IV. Provider business mailing address

520 S STATE ST APT 1502
CHICAGO IL
60605-1663
US

V. Phone/Fax

Practice location:
  • Phone: 773-377-5492
  • Fax:
Mailing address:
  • Phone: 559-917-5485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.008119
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number332074
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056013712
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: