| Entity Name: | CHRYSALIS COUNSELING CENTER, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 04 Jan 2019 (6 years ago) |
| Document Number: | L19000006493 |
| FEI/EIN Number | 83-3259684 |
| Address: | 4770 S. Ridgewood Ave, Suite 1, Port Orange, FL, 32127, US |
| Mail Address: | PO Box 290755, Port Orange, FL, 32129, US |
| ZIP code: | 32127 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1356956114 | 2020-09-09 | 2020-12-18 | 3930 S NOVA RD STE 303, PORT ORANGE, FL, 321279293, US | 3930 S NOVA RD STE 303, PORT ORANGE, FL, 321279293, US | |||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||
| Phone | +1 386-310-7436 |
| Fax | 3862596112 |
Authorized person
| Name | MS. BRENDA C ROCKWELL |
| Role | OWNER |
| Phone | 3863107436 |
Taxonomy
| Taxonomy Code | 101YM0800X - Mental Health Counselor |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 108142800 |
| State | FL |
| Issuer | MEDICAID |
| Number | 020114000 |
| State | FL |
| Name | Role |
|---|---|
| REGISTERED AGENTS INC | Agent |
| Name | Role | Address |
|---|---|---|
| Rockwell Brenda C | Owne | 4770 S. Ridgewood Ave, Port Orange, FL, 32127 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-03-05 | 4770 S. Ridgewood Ave, Suite 1, Port Orange, FL 32127 | No data |
| CHANGE OF MAILING ADDRESS | 2024-03-05 | 4770 S. Ridgewood Ave, Suite 1, Port Orange, FL 32127 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2019-03-25 | 7901 4TH STREET NORTH, SUITE 300, ST.PETERSBURG, FL 33702 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-05 |
| ANNUAL REPORT | 2023-01-30 |
| ANNUAL REPORT | 2022-01-25 |
| ANNUAL REPORT | 2021-03-16 |
| ANNUAL REPORT | 2020-02-05 |
| Florida Limited Liability | 2019-01-04 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
