Healthcare Provider Details

I. General information

NPI: 1720469570
Provider Name (Legal Business Name): BUBOLTZ & ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 WALNUT AVE
RUSTON LA
71270-5145
US

IV. Provider business mailing address

2101 WALNUT AVE
RUSTON LA
71270-5145
US

V. Phone/Fax

Practice location:
  • Phone: 318-512-9637
  • Fax:
Mailing address:
  • Phone: 318-512-9637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number870
License Number StateLA

VIII. Authorized Official

Name: WALTER BUBOLTZ
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 318-512-9637