Healthcare Provider Details

I. General information

NPI: 1831855352
Provider Name (Legal Business Name): ROOTS BEHAVIOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12535 NEW BRITTANY BLVD UNIT 2801
FORT MYERS FL
33907-3625
US

IV. Provider business mailing address

1510 OAK DR
FORT MYERS FL
33907-2816
US

V. Phone/Fax

Practice location:
  • Phone: 239-841-9035
  • Fax: 941-866-2685
Mailing address:
  • Phone: 239-841-9035
  • Fax: 941-866-2685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: YASHIRA N MARTINEZ
Title or Position: BCBA/OWNER
Credential:
Phone: 239-841-9035