Provider Demographics
NPI:1104145184
Name:TABLE ROCK INTEGRATED HEALTH AND WELLNESS PRACTICE, LLC.
Entity type:Organization
Organization Name:TABLE ROCK INTEGRATED HEALTH AND WELLNESS PRACTICE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GERGANA
Authorized Official - Middle Name:DAMIANOVA
Authorized Official - Last Name:DIMITROVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-908-6372
Mailing Address - Street 1:5 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-1826
Mailing Address - Country:US
Mailing Address - Phone:864-908-6372
Mailing Address - Fax:864-898-3703
Practice Address - Street 1:5 CENTER ST
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1826
Practice Address - Country:US
Practice Address - Phone:864-908-6372
Practice Address - Fax:864-898-3703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-31
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC307192084P0805X, 2084P0800X
SC58251041C0700X
SC1223101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty