| Entity Name: | BLACK SWAN COUNSELING SERVICES, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 15 Mar 2023 (2 years ago) |
| Document Number: | L23000134318 |
| FEI/EIN Number | 922920454 |
| Address: | 20 Lake Wire Drive, LAKELAND, FL, 33815, US |
| Mail Address: | 20 Lake Wire Dr, LAKELAND, FL, 33815, US |
| ZIP code: | 33815 |
| County: | Polk |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1841070109 | 2023-10-04 | 2023-10-04 | 1908 GRIFFINS GREEN BLVD, BARTOW, FL, 338307930, US | 122 E MAIN ST, LAKELAND, FL, 338014655, US | |||||||||||||
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| Phone | +1 863-667-8570 |
Authorized person
| Name | KEVIN BERRY |
| Role | MANAGING PARTNER |
| Phone | 8636678570 |
Taxonomy
| Taxonomy Code | 261QM0801X - Mental Health Clinic/Center (Including Community Mental Health Center) |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| BECKNER ALYSSIA | Agent | 1209 Edgewater Dr, LAKELAND, FL, 33805 |
| Name | Role | Address |
|---|---|---|
| MENDEZ JUAN LMFT | MGP | 5714 KEATON SPRINGS DRIVE, LAKELAND, FL, 33811 |
| BECKNER ALYSSIA | MGP | 1209 Edgewater Dr, LAKELAND, FL, 33805 |
| BERRY KEVIN | MGP | 1908 GRIFFINS GREEN BLVD, BARTOW, FL, 33830 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-01-27 | 20 Lake Wire Drive, Suite 183, LAKELAND, FL 33815 | No data |
| CHANGE OF MAILING ADDRESS | 2024-01-27 | 20 Lake Wire Drive, Suite 183, LAKELAND, FL 33815 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-01-27 | 1209 Edgewater Dr, LAKELAND, FL 33805 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-27 |
| Florida Limited Liability | 2023-03-15 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
