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NPI Code Detail

MEDICARE: DR. BIANCA ROE OTD, OTR/L, RDN, CLC

MEDICARE: DR. BIANCA ROE OTD, OTR/L, RDN, CLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian164.008119IL
2174N00000XLactation Consultant (Non-RN)332074
3225XP0200XPediatric Occupational Therapist056013712IL

General Provider Information

NPI Number : 1639553142
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. BIANCA ROE OTD, OTR/L, RDN, CLC
Provider Business Mailing Address
First Line : 520 S STATE ST APT 1502
Second Line :
City : CHICAGO
State : IL
Zip : 60605-1663
Country : US
Telephone Number : 559-917-5485
Fax Number :
Provider Business Practice Location Address
First Line : 3709 N KEDZIE AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60618-4503
Country : US
Telephone Number : 773-377-5492
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/14/2015
Last Update Date : 10/09/2024

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