Healthcare Provider Details

I. General information

NPI: 1417824350
Provider Name (Legal Business Name): LATEESHA T WALKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2025
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 RUSH ST
LAFAYETTE IN
47904-2625
US

IV. Provider business mailing address

1616 RUSH ST
LAFAYETTE IN
47904-2625
US

V. Phone/Fax

Practice location:
  • Phone: 765-237-9935
  • Fax:
Mailing address:
  • Phone: 765-237-9935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-481731
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: