Provider Demographics
NPI:1801002431
Name:WALTON BRUESKE COUNSELING GROUP PA
Entity Type:Organization
Organization Name:WALTON BRUESKE COUNSELING GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:904-733-9669
Mailing Address - Street 1:3810-1 WILLIAMSBURG PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-9217
Mailing Address - Country:US
Mailing Address - Phone:904-733-9669
Mailing Address - Fax:904-733-4194
Practice Address - Street 1:3810-1 WILLIAMSBURG PARK BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-9217
Practice Address - Country:US
Practice Address - Phone:904-733-9669
Practice Address - Fax:904-733-4194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH2109101YM0800X
FLMH209101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty