| Entity Name: | MELBOURNE MEDPSYCH, PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 18 Jul 2022 (3 years ago) |
| Document Number: | L22000317627 |
| FEI/EIN Number | 88-3351733 |
| Address: | 1915 OAK STREET, MELBOURNE, FL, 32901, US |
| Mail Address: | 406 AVENUE B, MELBOURNE BEACH, FL, 32951, US |
| ZIP code: | 32901 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1346977311 | 2022-08-01 | 2022-09-13 | 406 AVENUE B, MELBOURNE BEACH, FL, 329512215, US | 1915 OAK STREET, MELBOURNE, FL, 32901, US | |||||||||||||||||||||||||
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| Phone | +1 540-447-0134 |
| Fax | 5409327611 |
Authorized person
| Name | GERALD R SHOWALTER |
| Role | MBR |
| Phone | 5404470134 |
Taxonomy
| Taxonomy Code | 103G00000X - Clinical Neuropsychologist |
| Is Primary | Yes |
| Taxonomy Code | 103TC0700X - Clinical Psychologist |
| Is Primary | No |
Other Provider Identifiers
| Issuer | FLORIDA BOARD OF PSYCHOLOGY |
| Number | PY10639 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SHOWALTER GERALD R | Agent | 406 AVENUE B, MELBOURNE, FL, 32951 |
| Name | Role | Address |
|---|---|---|
| SHOWALTER GERALD R | Manager | 1915 OAK STREET, MELBOURNE, FL, 32901 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-11 |
| ANNUAL REPORT | 2023-02-01 |
| Florida Limited Liability | 2022-07-18 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
