Provider Demographics
NPI:1740802206
Name:ROOTS, ABA THERAPY AND CONSULTING SERVICES LLC
Entity Type:Organization
Organization Name:ROOTS, ABA THERAPY AND CONSULTING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ETIE
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BCBA, LBA
Authorized Official - Phone:512-423-4467
Mailing Address - Street 1:6104 OLD FREDERICKSBURG RD # 90851
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1216
Mailing Address - Country:US
Mailing Address - Phone:512-423-4467
Mailing Address - Fax:512-892-1422
Practice Address - Street 1:6104 OLD FREDERICKSBURG RD # 90851
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1216
Practice Address - Country:US
Practice Address - Phone:512-423-4467
Practice Address - Fax:512-892-1422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-07
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4307597Medicaid