Provider Demographics
NPI:1003797200
Name:WALBAUM, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:WALBAUM
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 1:200 HARTMAN CT
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1626
Mailing Address - Country:US
Mailing Address - Phone:765-404-9108
Mailing Address - Fax:
Practice Address - Street 1:3595 SAGAMORE PKWY N STE 5
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-1095
Practice Address - Country:US
Practice Address - Phone:765-637-8236
Practice Address - Fax:765-374-0443
Is Sole Proprietor?:No
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-25-471800103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst