Healthcare Provider Details

I. General information

NPI: 1003797200
Provider Name (Legal Business Name): ELLEN WALBAUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2025
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3595 SAGAMORE PKWY N STE 5
LAFAYETTE IN
47904-1095
US

IV. Provider business mailing address

200 HARTMAN CT
WEST LAFAYETTE IN
47906-1626
US

V. Phone/Fax

Practice location:
  • Phone: 765-637-8236
  • Fax: 765-374-0443
Mailing address:
  • Phone: 765-404-9108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberRBT-25-471800
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: