Provider Demographics
NPI:1184702151
Name:BROMAN-FULKS, JOSHUA JEFFERSON (PHD)
Entity type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:JEFFERSON
Last Name:BROMAN-FULKS
Suffix:
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 1:222 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5067
Mailing Address - Country:US
Mailing Address - Phone:828-406-1760
Mailing Address - Fax:828-262-2974
Practice Address - Street 1:222 BIRCH ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5067
Practice Address - Country:US
Practice Address - Phone:828-406-1760
Practice Address - Fax:828-264-6512
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3587103TC0700X, 103TB0200X, 103TE1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6001066Medicaid
NC069UWOtherBLUE CROSS BLUE SHIELD NORTH CAROLINA