| Entity Name: | BLOOM BEHAVIORAL HEALTH LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 24 May 2021 (4 years ago) |
| Document Number: | L21000240767 |
| FEI/EIN Number | APPLIED FOR |
| Address: | 2473 KARL DR, PORT ORANGE, FL 32128 |
| Mail Address: | 2473 KARL DR, PORT ORANGE, FL 32128 |
| ZIP code: | 32128 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1114593399 | 2021-05-28 | 2023-05-11 | 32 OLIVINE CT, SAINT AUGUSTINE, FL, 320860350, US | 2473 KARL DR, PORT ORANGE, FL, 321286511, US | |||||||||||||||||||||||||
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| Phone | +1 904-788-9474 |
| Fax | 7602054866 |
Authorized person
| Name | MRS. ELENA GONZALEZ |
| Role | OWNER |
| Phone | 9047889474 |
Taxonomy
| Taxonomy Code | 106H00000X - Marriage & Family Therapist |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | NPI |
| Number | 1164790143 |
| Issuer | NPI 1 |
| Number | 1164790143 |
| State | CA |
| Name | Role |
|---|---|
| UNITED STATES CORPORATION AGENTS, INC. | Agent |
| Name | Role | Address |
|---|---|---|
| GONZALEZ, ELENA | Authorized Member | 2473 KARL DR, PORT ORANGE, FL 32128 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G24000124333 | MINDFUL SOLUTIONS | ACTIVE | 2024-10-04 | 2029-12-31 | No data | 2473 KARL DR, PORT ORANGE, FL, 32128 |
| G24000074504 | COMPASS IMMIGRATION EVALUATIONS | ACTIVE | 2024-06-17 | 2029-12-31 | No data | 2473 KARL DR., PORT ORANGE, FL, 32128 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-04-02 | 2473 KARL DR, PORT ORANGE, FL 32128 | No data |
| CHANGE OF MAILING ADDRESS | 2024-04-02 | 2473 KARL DR, PORT ORANGE, FL 32128 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2023-02-18 | 476 RIVERSIDE AVE., JACKSONVILLE, FL 32202 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-02 |
| ANNUAL REPORT | 2023-04-18 |
| ANNUAL REPORT | 2022-04-18 |
| Florida Limited Liability | 2021-05-24 |
Date of last update: 14 Jan 2025
Sources: Florida Department of State
