Provider Demographics
NPI:1194951269
Name:FOULKE, BRYCE
Entity type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:FOULKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 CHARLES CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-8806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 CHARLES CT
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34771-8806
Practice Address - Country:US
Practice Address - Phone:321-624-5948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT 1033106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist