Provider Demographics
NPI:1639553142
Name:ROE, BIANCA (OTD, OTR/L, RDN, CLC)
Entity type:Individual
Prefix:DR
First Name:BIANCA
Middle Name:
Last Name:ROE
Suffix:
Gender:F
Credentials:OTD, OTR/L, RDN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S STATE ST APT 1502
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1663
Mailing Address - Country:US
Mailing Address - Phone:559-917-5485
Mailing Address - Fax:
Practice Address - Street 1:3709 N KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4503
Practice Address - Country:US
Practice Address - Phone:773-377-5492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.008119133V00000X
332074174N00000X
IL056013712225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN