Provider Demographics
NPI:1538697867
Name:ROOT, BILLIE NICOLE
Entity Type:Individual
Prefix:
First Name:BILLIE
Middle Name:NICOLE
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 1:419 RACETRACK RD NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-4612
Mailing Address - Country:US
Mailing Address - Phone:850-864-2273
Mailing Address - Fax:850-200-4745
Practice Address - Street 1:419 RACETRACK RD NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-4612
Practice Address - Country:US
Practice Address - Phone:850-864-2273
Practice Address - Fax:850-200-4745
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician