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BLACK SWAN COUNSELING SERVICES, LLC - Florida Company Profile

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Company Details

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: 100 S Kentucky Ave, LAKELAND, FL, 33801, US
Mail Address: 100 S Kentucky Ave, LAKELAND, FL, 33801, US
ZIP code: 33801
City: Lakeland
County: Polk
Place of Formation: FLORIDA

Key Officers & Management

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
BECKNER ALYSSIA Agent 100 S Kentucky Ave, LAKELAND, FL, 33801

National Provider Identifier

NPI Number:
1841070109
Certification Date:
2025-01-30

Authorized Person:

Name:
KEVIN BERRY
Role:
MANAGING PARTNER
Phone:

Taxonomy:

Selected Taxonomy:
261QM0801X - Mental Health Clinic/Center (Including Community Mental Health Center)
Is Primary:
Yes

Contacts:

Events

Event Type Filed Date Value Description
CHANGE OF PRINCIPAL ADDRESS 2025-01-30 100 S Kentucky Ave, Suite 240, LAKELAND, FL 33801 -
CHANGE OF MAILING ADDRESS 2025-01-30 100 S Kentucky Ave, Suite 240, LAKELAND, FL 33801 -
REGISTERED AGENT ADDRESS CHANGED 2025-01-30 100 S Kentucky Ave, Suite 240, LAKELAND, FL 33801 -
CHANGE OF PRINCIPAL ADDRESS 2024-01-27 20 Lake Wire Drive, Suite 183, LAKELAND, FL 33815 -
CHANGE OF MAILING ADDRESS 2024-01-27 20 Lake Wire Drive, Suite 183, LAKELAND, FL 33815 -
REGISTERED AGENT ADDRESS CHANGED 2024-01-27 1209 Edgewater Dr, LAKELAND, FL 33805 -

Documents

Name Date
ANNUAL REPORT 2025-01-30
ANNUAL REPORT 2024-01-27
Florida Limited Liability 2023-03-15

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Date of last update: 03 Aug 2025

Sources: Florida Department of State