Provider Demographics
NPI:1063227825
Name:OBERDORF, SUELLEN M (RBT)
Entity type:Individual
Prefix:
First Name:SUELLEN
Middle Name:M
Last Name:OBERDORF
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:SUELLEN
Other - Middle Name:M
Other - Last Name:OBERDORF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RBT
Mailing Address - Street 1:127 CONNOLLY ST
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-2721
Mailing Address - Country:US
Mailing Address - Phone:765-469-2338
Mailing Address - Fax:
Practice Address - Street 1:127 CONNOLLY ST
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-2721
Practice Address - Country:US
Practice Address - Phone:765-469-2338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-24-331920106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician