Provider Demographics
NPI:1548939739
Name:ROBERTS, BIANCA STARSHAWNA
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:STARSHAWNA
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1992 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-5707
Mailing Address - Country:US
Mailing Address - Phone:774-328-5197
Mailing Address - Fax:
Practice Address - Street 1:124 WATERTOWN ST STE 2D
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2500
Practice Address - Country:US
Practice Address - Phone:617-916-5069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program