Provider Demographics
NPI:1124253125
Name:ROOT, SHANNON (BCBA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROOT
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1057
Mailing Address - Street 2:
Mailing Address - City:LAKE ALFRED
Mailing Address - State:FL
Mailing Address - Zip Code:33850-1057
Mailing Address - Country:US
Mailing Address - Phone:863-551-3300
Mailing Address - Fax:863-551-3301
Practice Address - Street 1:117 E LAKE AVE
Practice Address - Street 2:SUITE D
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-3437
Practice Address - Country:US
Practice Address - Phone:863-551-3300
Practice Address - Fax:863-551-3301
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-03-1417103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL675822396OtherMEDWAIVER
FL675822398OtherMEDWAIVER