| Entity Name: | EARTH HAVEN THERAPY INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Non-Profit |
| Status: | Active |
| Date Filed: | 27 Sep 2021 (3 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 15 Dec 2021 (3 years ago) |
| Document Number: | N21000011425 |
| FEI/EIN Number | 87-2819094 |
| Address: | 8760 SW 21ST CT, OCALA, FL, 34476, US |
| Mail Address: | 2647 Thomas St, Hollywood, FL, 33020, US |
| ZIP code: | 34476 |
| County: | Marion |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1407447600 | 2021-01-29 | 2021-11-25 | 8760 SW 21ST CT, OCALA, FL, 344766732, US | 8760 SW 21ST CT, OCALA, FL, 344766732, US | |||||||||||||||||||||
|
|||||||||||||||||||||||||
| Phone | +1 818-272-6442 |
| Fax | 7143334407 |
Authorized person
| Name | LINDA MONIQUE BERT |
| Role | LMFT |
| Phone | 8182726442 |
Taxonomy
| Taxonomy Code | 106H00000X - Marriage & Family Therapist |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 108285000 |
| State | FL |
| Name | Role |
|---|---|
| BEACH BEHAVIORAL LLC | Agent |
| Name | Role | Address |
|---|---|---|
| BERT LINDA | President | 8760 SW 21ST CT, OCALA, FL, 34476 |
| Name | Role | Address |
|---|---|---|
| REGESTER SHANTI | Vice President | 8760 SW 21ST CT, OCALA, FL, 34476 |
| Name | Role | Address |
|---|---|---|
| MARTIN JACQUELINE R | Secretary | 8902 SW 191ST CIRCLE, DUNNELLON, FL, 34432 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2023-04-11 | 8760 SW 21ST CT, OCALA, FL 34476 | No data |
| AMENDMENT | 2021-12-15 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-21 |
| ANNUAL REPORT | 2023-04-11 |
| ANNUAL REPORT | 2022-02-02 |
| Amendment | 2021-12-15 |
| Domestic Non-Profit | 2021-09-27 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
