Healthcare Provider Details

I. General information

NPI: 1356205439
Provider Name (Legal Business Name): ROOTED ABA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2921 N DUNN ST
BLOOMINGTON IN
47408-1055
US

IV. Provider business mailing address

2921 N DUNN ST
BLOOMINGTON IN
47408-1055
US

V. Phone/Fax

Practice location:
  • Phone: 812-929-2212
  • Fax:
Mailing address:
  • Phone: 812-929-2212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: SHAYNA SURVIL
Title or Position: CO-FOUNDER
Credential:
Phone: 812-929-2212