Healthcare Provider Details

I. General information

NPI: 1033005509
Provider Name (Legal Business Name): INTEGRATIVE WELLNESS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2025
Last Update Date: 06/22/2025
Certification Date: 06/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16410 WINDSOR CAY BLVD APT 102
CLERMONT FL
34714-7306
US

IV. Provider business mailing address

16410 WINDSOR CAY BLVD APT 102
CLERMONT FL
34714-7306
US

V. Phone/Fax

Practice location:
  • Phone: 352-562-0741
  • Fax:
Mailing address:
  • Phone: 352-562-0741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MRS. KORINA DANIELA HERRERA
Title or Position: MEMBER/OWNER
Credential: LMHC
Phone: 352-562-0741