| Entity Name: | REVIBE THERAPY PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 12 Feb 2018 (7 years ago) |
| Last Event: | LC STMNT OF RA/RO CHG |
| Event Date Filed: | 12 Dec 2023 (a year ago) |
| Document Number: | L18000038807 |
| FEI/EIN Number | 83-3780493 |
| Address: | 7901 4th St N, St. Petersburg, FL, 33702, US |
| Mail Address: | 7901 4th St N, St. Petersburg, FL, 33702, US |
| ZIP code: | 33702 |
| County: | Pinellas |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1457919516 | 2019-06-04 | 2020-05-29 | 11901 LANDING POINT LOOP, ORLANDO, FL, 328325904, US | 6900 TAVISTOCK LAKES BLVD STE 400, ORLANDO, FL, 328277593, US | |||||||||||||||||||
|
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| Phone | +1 407-801-2191 |
Authorized person
| Name | MR. JOSE MIGUEL DE LA CRUZ JR. |
| Role | HYPNOTHERAPIST/ PSYCHOTHERAPIST |
| Phone | 4078012191 |
Taxonomy
| Taxonomy Code | 1041C0700X - Clinical Social Worker |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 1629635073 |
| State | FL |
| Name | Role |
|---|---|
| REGISTERED AGENTS INC | Agent |
| Name | Role | Address |
|---|---|---|
| DE LA CRUZ JOSE | Auth | 7901 4th St N, St. Petersburg, FL, 33702 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-03-15 | 7901 4th St N, STE 300, St. Petersburg, FL 33702 | No data |
| CHANGE OF MAILING ADDRESS | 2024-03-15 | 7901 4th St N, STE 300, St. Petersburg, FL 33702 | No data |
| LC STMNT OF RA/RO CHG | 2023-12-12 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2023-12-12 | REGISTERED AGENTS INC | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2023-12-12 | 7901 4TH ST N STE 300, ST. PETERSBURG, FL 33702 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-15 |
| CORLCRACHG | 2023-12-12 |
| ANNUAL REPORT | 2023-04-06 |
| ANNUAL REPORT | 2022-04-12 |
| ANNUAL REPORT | 2021-04-26 |
| ANNUAL REPORT | 2020-02-17 |
| ANNUAL REPORT | 2019-03-09 |
| Florida Limited Liability | 2018-02-12 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
