Provider Demographics
NPI:1740361484
Name:ROE, ANDREA T (AUD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:T
Last Name:ROE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 N SEMINARY ST
Mailing Address - Street 2:SUITE 405
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2852
Mailing Address - Country:US
Mailing Address - Phone:309-343-1632
Mailing Address - Fax:309-343-1785
Practice Address - Street 1:834 N SEMINARY ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2852
Practice Address - Country:US
Practice Address - Phone:309-343-1632
Practice Address - Fax:309-343-1785
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00597231H00000X
IA00890237600000X
IL147.001190231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1740361484Medicaid
IA118667Medicare UPIN
IL200831002Medicare UPIN
ILK31413Medicare UPIN
IA1740361484Medicaid