Healthcare Provider Details

I. General information

NPI: 1184702151
Provider Name (Legal Business Name): JOSHUA JEFFERSON BROMAN-FULKS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 BIRCH ST
BOONE NC
28607-5067
US

IV. Provider business mailing address

222 BIRCH ST
BOONE NC
28607-5067
US

V. Phone/Fax

Practice location:
  • Phone: 828-406-1760
  • Fax: 828-264-6512
Mailing address:
  • Phone: 828-406-1760
  • Fax: 828-262-2974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3587
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number3587
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number3587
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: