MEDICARE: WILLIAM BENNETT ROOT BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	2025015484	MO

General Provider Information

NPI Number	:	1942195318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM BENNETT ROOT BCBA

Provider Business Mailing Address
First Line	:	106 S FARRAR DR
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-4902
Country	:	US
Telephone Number	:	618-201-5823
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 S FARRAR DR
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-4902
Country	:	US
Telephone Number	:	618-201-5823
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2025
Last Update Date	:	03/15/2026

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