Healthcare Provider Details

I. General information

NPI: 1336737675
Provider Name (Legal Business Name): ACTIVE WELLNESS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 S MAIN ST
TRENTON FL
32693-3236
US

IV. Provider business mailing address

605 S MAIN ST
TRENTON FL
32693-3236
US

V. Phone/Fax

Practice location:
  • Phone: 386-961-9616
  • Fax:
Mailing address:
  • Phone: 386-961-9616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY CARPENTER HERRING
Title or Position: OWNER
Credential: LCSW
Phone: 386-397-0696