| Entity Name: | PALM COAST COUNSELING, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 05 Dec 2019 (5 years ago) |
| Last Event: | LC AMENDMENT |
| Event Date Filed: | 06 Mar 2024 (a year ago) |
| Document Number: | L19000297365 |
| FEI/EIN Number | 84-3937193 |
| Address: | 160 cypress point pkwy, Ste B302, PALM COAST, FL 32164 |
| Mail Address: | 160 cypress point pkwy, Ste B302, PALM COAST, FL 32164 |
| ZIP code: | 32164 |
| County: | Flagler |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1407357437 | 2018-02-25 | 2020-06-15 | 54 WELLESLEY LN, PALM COAST, FL, 321647867, US | 1 HARGROVE GRADE, STE B-1, PALM COAST, FL, 32137, US | |||||||||||||||||||||||||||||
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| Phone | +1 386-643-3115 |
| Fax | 3862763474 |
Authorized person
| Name | CYNTHIA D HAIRSTON |
| Role | OWNER/ADMINISTRATOR |
| Phone | 3864510684 |
Taxonomy
| Taxonomy Code | 101YM0800X - Mental Health Counselor |
| License Number | MH12217 |
| 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 | 010691000 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| DIXON, DE-SHAUNAH | Agent | 515 PALM COAST PARKWAY SW,#5, PALM COAST, FL 32137 |
| Name | Role | Address |
|---|---|---|
| DIXON, DESHAUNAH | Authorized Member | 515 Palm Coast Parkway SW, #5, PALM COAST, FL 32137 |
| DIXON, DE-SHAUNAH | Authorized Member | 515 PALM COAST PARKWAY SW #5, PALM COAST, FL 32137 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-07-25 | 160 cypress point pkwy, Ste B302, PALM COAST, FL 32164 | No data |
| CHANGE OF MAILING ADDRESS | 2024-07-25 | 160 cypress point pkwy, Ste B302, PALM COAST, FL 32164 | No data |
| LC AMENDMENT | 2024-03-06 | No data | No data |
| Name | Date |
|---|---|
| LC Amendment | 2024-03-06 |
| AMENDED ANNUAL REPORT | 2024-02-29 |
| ANNUAL REPORT | 2024-01-31 |
| ANNUAL REPORT | 2023-01-28 |
| AMENDED ANNUAL REPORT | 2022-10-03 |
| ANNUAL REPORT | 2022-04-15 |
| AMENDED ANNUAL REPORT | 2021-08-09 |
| ANNUAL REPORT | 2021-03-30 |
| ANNUAL REPORT | 2020-01-15 |
| Florida Limited Liability | 2019-12-05 |
Date of last update: 15 Feb 2025
Sources: Florida Department of State
