Healthcare Provider Details

I. General information

NPI: 1104145184
Provider Name (Legal Business Name): TABLE ROCK INTEGRATED HEALTH AND WELLNESS PRACTICE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2010
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 CENTER ST
TRAVELERS REST SC
29690-1826
US

IV. Provider business mailing address

5 CENTER ST
TRAVELERS REST SC
29690-1826
US

V. Phone/Fax

Practice location:
  • Phone: 864-908-6372
  • Fax: 864-898-3703
Mailing address:
  • Phone: 864-908-6372
  • Fax: 864-898-3703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1223
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5825
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number30719
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number30719
License Number StateSC

VIII. Authorized Official

Name: MRS. GERGANA DAMIANOVA DIMITROVA
Title or Position: PARTNER
Credential: M.D.
Phone: 864-908-6372