Provider Demographics
NPI:1093339509
Name:ROOT, MADISON ASHLEY
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ASHLEY
Last Name:ROOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 LIGHT ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-4307
Mailing Address - Country:US
Mailing Address - Phone:412-926-8558
Mailing Address - Fax:
Practice Address - Street 1:7090 SAMUEL MORSE DR STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-3444
Practice Address - Country:US
Practice Address - Phone:724-933-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-31
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MD1-21-56938103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician