Healthcare Provider Details

I. General information

NPI: 1689505091
Provider Name (Legal Business Name): BIANCA RENEE RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 SHERWOOD DR STE 201
LAKE BLUFF IL
60044-2235
US

IV. Provider business mailing address

2717 NORTHFIELD AVE
WAUKEGAN IL
60085-2469
US

V. Phone/Fax

Practice location:
  • Phone: 847-482-1205
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: