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  5. LEESBURG PSYCHOLOGY LLC

LEESBURG PSYCHOLOGY LLC

Company Details

Entity Name: LEESBURG PSYCHOLOGY LLC
Jurisdiction: FLORIDA
Filing Type: Florida Limited Liability Co.
Status: Inactive
Date Filed: 22 Mar 2010 (15 years ago)
Date of dissolution: 23 Sep 2022 (2 years ago)
Last Event: ADMIN DISSOLUTION FOR ANNUAL REPORT
Event Date Filed: 23 Sep 2022 (2 years ago)
Document Number: L10000030901
FEI/EIN Number 272155329
Address: 36203 Lake Unity Nursery RD, Fruitland Park, FL, 34731, US
Mail Address: 36203 Lake Unity Nursery RD, Fruitland Park, FL, 34731, US
ZIP code: 34731
County: Lake
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1710204292 2010-04-23 2010-05-10 8529 US HIGHWAY 441, LEESBURG, FL, 347884021, US 8529 US HIGHWAY 441, LEESBURG, FL, 347884021, US

Contacts
Phone +1 352-787-7144
Fax 3524507600

Authorized person
Name DR. EVELYN R. BAEZ-ROJAS
Role OWNER
Phone 3527877144

Taxonomy
Taxonomy Code 103TC0700X - Clinical Psychologist
License Number PY4794
State FL
Is Primary Yes

Other Provider Identifiers
Issuer BLUE CROSS AND BLUE SHIELD OF FLORIDA
Number 59515
State FL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
LEESBURG PSYCHOLOGY, LLC 401K PROFIT SHARING PLAN 2021 272155329 2022-07-19 LEESBURG PSYCHOLOGY, LLC 2
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2012-01-01
Business code 621112
Sponsor’s telephone number 3527877144
Plan sponsor’s address 8527 US HIGHWAY 441, LEESBURG, FL, 34788

Signature of
Role Plan administrator
Date 2022-07-19
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2022-07-19
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
LEESBURG PSYCHOLOGY, LLC 401K PROFIT SHARING PLAN 2020 272155329 2021-09-09 LEESBURG PSYCHOLOGY, LLC 2
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2012-01-01
Business code 621112
Sponsor’s telephone number 3527877144
Plan sponsor’s address 8527 US HIGHWAY 441, LEESBURG, FL, 34788

Signature of
Role Plan administrator
Date 2021-09-09
Name of individual signing EVELYN BAEZ ROJAS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2021-09-09
Name of individual signing EVELYN BAEZ ROJAS
Valid signature Filed with authorized/valid electronic signature
LEESBURG PSYCHOLOGY, LLC 401K PROFIT SHARING PLAN 2019 272155329 2020-10-15 LEESBURG PSYCHOLOGY, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2012-01-01
Business code 621112
Sponsor’s telephone number 3527877144
Plan sponsor’s address 8527 US HIGHWAY 441, LEESBURG, FL, 34788

Signature of
Role Plan administrator
Date 2020-10-15
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2020-10-15
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
LEESBURG PSYCHOLOGY, LLC 401K PROFIT SHARING PLAN 2018 272155329 2019-07-25 LEESBURG PSYCHOLOGY, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2012-01-01
Business code 621112
Sponsor’s telephone number 3527877144
Plan sponsor’s address 8527 US HIGHWAY 441, LEESBURG, FL, 34788

Signature of
Role Plan administrator
Date 2019-07-25
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2019-07-25
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
LEESBURG PSYCHOLOGY, LLC 401K PROFIT SHARING PLAN 2017 272155329 2018-08-21 LEESBURG PSYCHOLOGY, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2012-01-01
Business code 621112
Sponsor’s telephone number 3527877144
Plan sponsor’s address 8529 US HIGHWAY 441, LEESBURG, FL, 34788

Signature of
Role Plan administrator
Date 2018-08-21
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2018-08-21
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
LEESBURG PSYCHOLOGY, LLC 401K PROFIT SHARING PLAN 2016 272155329 2017-10-12 LEESBURG PSYCHOLOGY, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2012-01-01
Business code 621112
Sponsor’s telephone number 3527877144
Plan sponsor’s address 8529 US HIGHWAY 441, LEESBURG, FL, 34788

Signature of
Role Plan administrator
Date 2017-10-12
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2017-10-12
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
LEESBURG PSYCHOLOGY, LLC 401K PROFIT SHARING PLAN 2015 272155329 2016-08-02 LEESBURG PSYCHOLOGY, LLC 2
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2012-01-01
Business code 621112
Sponsor’s telephone number 3527877144
Plan sponsor’s address 8529 US HIGHWAY 441, LEESBURG, FL, 34788

Signature of
Role Plan administrator
Date 2016-08-02
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2016-08-02
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
LEESBURG PSYCHOLOGY, LLC 401K PROFIT SHARING PLAN 2014 272155329 2015-07-31 LEESBURG PSYCHOLOGY, LLC 2
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2012-01-01
Business code 621112
Sponsor’s telephone number 3527877144
Plan sponsor’s address 8529 US HIGHWAY 441, LEESBURG, FL, 34788

Signature of
Role Plan administrator
Date 2015-07-31
Name of individual signing DR. EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2015-07-31
Name of individual signing DR. EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
LEESBURG PSYCHOLOGY, LLC 401K PROFIT SHARING PLAN 2013 272155329 2014-07-29 LEESBURG PSYCHOLOGY, LLC 2
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2012-01-01
Business code 621112
Sponsor’s telephone number 3527877144
Plan sponsor’s address 8529 US HIGHWAY 441, LEESBURG, FL, 34788

Signature of
Role Plan administrator
Date 2014-07-29
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2014-07-29
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature
LEESBURG PSYCHOLOGY, LLC 401K PROFIT SHARING PLAN 2012 272155329 2013-10-15 LEESBURG PSYCHOLOGY, LLC 1
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2012-01-01
Business code 621112
Sponsor’s telephone number 3527877144
Plan sponsor’s address 8529 US HIGHWAY 441, LEESBURG, FL, 34788

Signature of
Role Plan administrator
Date 2013-10-15
Name of individual signing EVELYN BAEZ ROJAS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2013-10-15
Name of individual signing EVELYN BAEZ-ROJAS
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
BAEZ-ROJAS EVELYN RPhd Agent 36203 LAKE UNITY NURSERY RD, FRUITLAND PARK, FL, 34731

President

Name Role Address
BAEZ-ROJAS EVELYN President 36203 LAKE UNITY NURSERY RD, FRUITLAND PARK, FL, 34731

Events

Event Type Filed Date Value Description
ADMIN DISSOLUTION FOR ANNUAL REPORT 2022-09-23 No data No data
CHANGE OF PRINCIPAL ADDRESS 2021-02-05 36203 Lake Unity Nursery RD, Fruitland Park, FL 34731 No data
CHANGE OF MAILING ADDRESS 2021-02-05 36203 Lake Unity Nursery RD, Fruitland Park, FL 34731 No data
REGISTERED AGENT NAME CHANGED 2018-01-22 BAEZ-ROJAS, EVELYN R, Phd No data

Documents

Name Date
ANNUAL REPORT 2021-02-05
ANNUAL REPORT 2020-01-17
ANNUAL REPORT 2019-04-03
ANNUAL REPORT 2018-01-22
ANNUAL REPORT 2017-05-04
ANNUAL REPORT 2016-02-17
ANNUAL REPORT 2015-01-11
ANNUAL REPORT 2014-01-27
ANNUAL REPORT 2013-01-15
ANNUAL REPORT 2012-01-14

Related by officers

BAEZ-ROJAS EVELYN

EROJAS INVESTMENT PROPERTIES LLC

Related by address

No related companies by address

Date of last update: 01 Feb 2025

Sources: Florida Department of State

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