Provider Demographics
NPI:1689779183
Name:FUNDERBURK, DIANE BRACKEN (DPT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:BRACKEN
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 ROCK HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-7627
Mailing Address - Country:US
Mailing Address - Phone:864-993-4777
Mailing Address - Fax:
Practice Address - Street 1:437 E CAMBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2244
Practice Address - Country:US
Practice Address - Phone:864-330-3000
Practice Address - Fax:864-388-7318
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC913225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0631Medicaid