Provider Demographics
NPI:1235570573
Name:BUBOLTZ, WALTER C JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:C
Last Name:BUBOLTZ
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5145
Mailing Address - Country:US
Mailing Address - Phone:318-512-9637
Mailing Address - Fax:
Practice Address - Street 1:2101 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5145
Practice Address - Country:US
Practice Address - Phone:318-512-9637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA870103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling