Provider Demographics
NPI:1740888452
Name:ROOT, TROY MICHAEL
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:MICHAEL
Last Name:ROOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 POLK ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1513
Mailing Address - Country:US
Mailing Address - Phone:970-539-6483
Mailing Address - Fax:
Practice Address - Street 1:401 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2127
Practice Address - Country:US
Practice Address - Phone:970-539-6483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-20-140219106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician