| Entity Name: | SOUTHERN PSYCHIATRY LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 01 Feb 2019 (6 years ago) |
| Document Number: | L19000028086 |
| FEI/EIN Number | 83-3067501 |
| Address: | 3906 US Highway 98, Santa Rosa Beach, FL, 32459, UN |
| Mail Address: | 201 N BLUE HERON DR, SANTA ROSA BEACH, FL, 32459, UN |
| ZIP code: | 32459 |
| County: | Walton |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1467917898 | 2019-02-11 | 2022-12-15 | 201 N BLUE HERON DR, SANTA ROSA BEACH, FL, 324593039, US | 500 HOSPITAL DR, CRESTVIEW, FL, 325397355, US | |||||||||||||||||||||
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| Phone | +1 850-687-0887 |
Authorized person
| Name | RENEE MCCORMACK |
| Role | OWNER |
| Phone | 8506870887 |
Taxonomy
| Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
| Is Primary | No |
| Taxonomy Code | 363LP0808X - Psychiatric/Mental Health Nurse Practitioner |
| Is Primary | Yes |
| Taxonomy Code | 363LP2300X - Primary Care Nurse Practitioner |
| Is Primary | No |
| Name | Role | Address |
|---|---|---|
| MCCORMACK RENEE R | Agent | 201 N BLUE HERON DR, SANTA ROSA BEACH, FL, 32459 |
| Name | Role | Address |
|---|---|---|
| MCCORMACK JOSEPH IJR. | Manager | 201 N BLUE HERON DR, SANTA ROSA BEACH, FL, 32459 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G19000072867 | NOMADIC NURSE | EXPIRED | 2019-07-01 | 2024-12-31 | No data | 3906 US 98 W #1522, SANTA ROSA BEACH, FL, 32459 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2021-03-19 | 3906 US Highway 98, #1522, Santa Rosa Beach, FL - FLORIDA 32459 UN | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-22 |
| ANNUAL REPORT | 2023-01-20 |
| ANNUAL REPORT | 2022-01-30 |
| ANNUAL REPORT | 2021-03-19 |
| ANNUAL REPORT | 2020-02-14 |
| Florida Limited Liability | 2019-02-01 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
