| Entity Name: | BLACK MENTAL HEALTH TAMPA BAY LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 09 Aug 2024 (6 months ago) |
| Document Number: | L24000349856 |
| Address: | 7402 N 56TH ST, STE 355 PMB 2073, TAMPA, FL, 33617 |
| Mail Address: | 3975 ADDLESTONE AVE, APT 113, WESLEY CHAPEL, FL, FL, 33543 |
| ZIP code: | 33617 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1528890126 | 2024-08-14 | 2024-08-14 | 3975 ADDLESTONE AVE UNIT 113, WESLEY CHAPEL, FL, 335435582, US | 7402 N 56TH ST STE 355, TAMPA, FL, 336177700, US | |||||||||||||||
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| Phone | +1 813-451-4359 |
| Fax | 8134514359 |
Authorized person
| Name | RAVEEN FLORENCE |
| Role | LCSW |
| Phone | 8134514359 |
Taxonomy
| Taxonomy Code | 251S00000X - Community/Behavioral Health Agency |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| FLORENCE RAVEEN NMS | Agent | 7402 N 56TH ST, TAMPA, FL, 33617 |
| Name | Role | Address |
|---|---|---|
| FLORENCE RAVEEN NMS | Authorized Representative | 7402 N 56TH ST STE 355 PMB 2073, TAMPA, FL, 33617 |
| Name | Role | Address |
|---|---|---|
| JOHNSON PHEKILA MS | Authorized Person | 7402 N 56TH ST STE 355 PMB 2073, TAMPA, FL, 33617 |
| Name | Date |
|---|---|
| Florida Limited Liability | 2024-08-09 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
