Provider Demographics
NPI:1477294049
Name:BEHAVIORAL ROOTS, LLC
Entity Type:Organization
Organization Name:BEHAVIORAL ROOTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:405-215-9073
Mailing Address - Street 1:617 NW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-7342
Mailing Address - Country:US
Mailing Address - Phone:405-215-9073
Mailing Address - Fax:405-353-7002
Practice Address - Street 1:617 NW 32ND ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-7342
Practice Address - Country:US
Practice Address - Phone:405-215-9073
Practice Address - Fax:405-353-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty