| Entity Name: | COLLABORATIVE PSYCH & MED, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 22 Aug 2018 (6 years ago) |
| Date of dissolution: | 24 Sep 2021 (3 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 24 Sep 2021 (3 years ago) |
| Document Number: | L18000200718 |
| FEI/EIN Number | 83-1706764 |
| Address: | 3353 Victoria Manor Drive, LAKELAND, FL, 33805, US |
| Mail Address: | 3353 Victoria Manor Drive, LAKELAND, FL, 33805, US |
| ZIP code: | 33805 |
| County: | Polk |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1972088912 | 2018-09-26 | 2018-09-26 | 4406 S FLORIDA AVE STE 31, LAKELAND, FL, 338132176, US | 4406 S FLORIDA AVE STE 31, LAKELAND, FL, 338132176, US | |||||||||||||||||||||||
|
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| Phone | +1 855-732-5292 |
| Fax | 8635839926 |
Authorized person
| Name | KELLY WOOD |
| Role | ADMINISTRATOR |
| Phone | 8557325292 |
Taxonomy
| Taxonomy Code | 103TA0700X - Adult Development & Aging Psychologist |
| Is Primary | No |
| Taxonomy Code | 171M00000X - Case Manager/Care Coordinator |
| Is Primary | No |
| Taxonomy Code | 2084P0805X - Geriatric Psychiatry Physician |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| Brannen Catherine | Agent | 3353 Victoria Manor Drive, LAKELAND, FL, 33805 |
| Name | Role | Address |
|---|---|---|
| MOORE JULIUS DDR. | Manager | 4404 S FLORIDA AVENUE, LAKELAND, FL, 33813 |
| Name | Role | Address |
|---|---|---|
| BRANNEN CATHERINE | Authorized Member | 4404 S FLORIDA AVENUE, LAKELAND, FL, 33813 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2021-09-24 | No data | No data |
| LC AMENDMENT | 2020-07-16 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2020-02-22 | 3353 Victoria Manor Drive, K 109, LAKELAND, FL 33805 | No data |
| CHANGE OF MAILING ADDRESS | 2020-02-22 | 3353 Victoria Manor Drive, K 109, LAKELAND, FL 33805 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2020-02-22 | 3353 Victoria Manor Drive, K 109, LAKELAND, FL 33805 | No data |
| REGISTERED AGENT NAME CHANGED | 2019-01-21 | Brannen, Catherine | No data |
| Document Number | Status | Case Number | Name of Court | Date of Entry | Expiration Date | Amount Due | Plaintiff |
|---|---|---|---|---|---|---|---|
| J23000458992 | ACTIVE | 1000000964596 | POLK | 2023-09-22 | 2033-09-27 | $ 660.14 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, LAKELAND SERVICE CENTER, 115 S MISSOURI AVE STE 202, LAKELAND FL338154644 |
| J21000391429 | ACTIVE | 1000000896845 | POLK | 2021-07-30 | 2031-08-04 | $ 663.92 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, LAKELAND SERVICE CENTER, 115 S MISSOURI AVE STE 202, LAKELAND FL338154644 |
| Name | Date |
|---|---|
| LC Amendment | 2020-07-16 |
| ANNUAL REPORT | 2020-02-22 |
| ANNUAL REPORT | 2019-01-21 |
| Florida Limited Liability | 2018-08-22 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
