Healthcare Provider Details

I. General information

NPI: 1538029293
Provider Name (Legal Business Name): INNOVATIVE WELLNESS SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2025
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 IMPATIEN DR
CHARLOTTE NC
28215-7739
US

IV. Provider business mailing address

2520 IMPATIEN DR
CHARLOTTE NC
28215-7739
US

V. Phone/Fax

Practice location:
  • Phone: 917-841-7842
  • Fax:
Mailing address:
  • Phone: 917-841-7842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. GEORGINA FIORENTINO
Title or Position: LCASA COUNSELOR/TCM SUPERVISOR
Credential: EDD, LCASA
Phone: 917-841-7842