| Entity Name: | FLORIDA PSYCHOLOGICAL ASSOCIATES LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 12 Nov 2014 (10 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 13 Oct 2020 (4 years ago) |
| Document Number: | L14000179144 |
| FEI/EIN Number | 47-2333193 |
| Address: | 1903 Island Walk, FERNANDINA BEACH, FL 32034 |
| Mail Address: | 1903 Island Walk, FERNANDINA BEACH, FL 32034 |
| ZIP code: | 32034 |
| County: | Nassau |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1922496850 | 2014-12-30 | 2017-03-23 | 1903 ISLAND WALK WAY, FERNANDINA, FL, 320344797, US | 1903 ISLAND WALK WAY, FERNANDINA, FL, 320344797, US | |||||||||||||||||||||||||||||||
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| Phone | +1 904-277-0027 |
Authorized person
| Name | DR. CATHERINE H DREW |
| Role | CEO |
| Phone | 9042770027 |
Taxonomy
| Taxonomy Code | 104100000X - Social Worker |
| Is Primary | No |
| Taxonomy Code | 251S00000X - Community/Behavioral Health Agency |
| License Number | ATN 581436 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 261QM0801X - Mental Health Clinic/Center (Including Community Mental Health Center) |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | ATN 581436 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| FLORIDA PSYCHOLOGICAL ASSOCIATES 401(K) PLAN | 2023 | 472333193 | 2024-05-16 | FLORIDA PSYCHOLOGICAL ASSOCIATES | 29 | |||||||||||||||||||||||||||||||
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| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 1412 CHAPIN AVENUE, BURLINGAME, CA, 94010 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2024-05-16 |
| Name of individual signing | QIAN LIU |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2021-01-01 |
| Business code | 621330 |
| Sponsor’s telephone number | 9042770027 |
| Plan sponsor’s address | 1903 ISLAND WALK WAY, FERNANDINA, FL, 320344797 |
Plan administrator’s name and address
| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 1412 CHAPIN AVENUE, BURLINGAME, CA, 94010 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2023-08-11 |
| Name of individual signing | CHRISTINE RIMER |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2021-01-01 |
| Business code | 621330 |
| Sponsor’s telephone number | 9042770027 |
| Plan sponsor’s address | 1903 ISLAND WALK WAY, FERNANDINA, FL, 320344797 |
Plan administrator’s name and address
| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 1645 E 6TH STREET, SUITE 200, AUSTIN, TX, 78702 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2022-06-01 |
| Name of individual signing | CHRISTINE RIMER |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| DREW, CATHERINE H, DR. | Agent | 1903 Island Walk, FERNANDINA BEACH, FL 32034 |
| Name | Role | Address |
|---|---|---|
| HUME, LAURA | Authorized Member | 1903 ISLAND WALKWAY, FERNANDINA BEACH, FL 32036 |
| DREW, CATHERINE | Authorized Member | 1903 ISLAND WALKWAY, FERNANDINA BEACH, FL 32036 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2020-10-13 | DREW, CATHERINE H, DR. | No data |
| REINSTATEMENT | 2020-10-13 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2020-10-13 | 1903 Island Walk, FERNANDINA BEACH, FL 32034 | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2020-09-25 | No data | No data |
| LC AMENDMENT | 2019-03-22 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2018-03-13 | 1903 Island Walk, FERNANDINA BEACH, FL 32034 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2017-04-19 | 1903 Island Walk, FERNANDINA BEACH, FL 32034 | No data |
| LC AMENDMENT | 2015-02-17 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-30 |
| ANNUAL REPORT | 2023-03-30 |
| ANNUAL REPORT | 2022-03-07 |
| ANNUAL REPORT | 2021-05-07 |
| REINSTATEMENT | 2020-10-13 |
| ANNUAL REPORT | 2019-04-08 |
| LC Amendment | 2019-03-22 |
| ANNUAL REPORT | 2018-03-13 |
| ANNUAL REPORT | 2017-04-19 |
| ANNUAL REPORT | 2016-04-21 |
| Loan Number | Loan Funded Date | SBA Origination Office Code | Loan Delivery Method | Borrower Street Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4762737202 | 2020-04-27 | 0491 | PPP | 1903 ISLAND WALK WAY, FERNANDINA BEACH, FL, 32034-4797 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Date of last update: 20 Feb 2025
Sources: Florida Department of State
