| Entity Name: | FORT MYERS PSYCHOLOGY, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 23 May 2006 (19 years ago) |
| Last Event: | NAME CHANGE AMENDMENT |
| Event Date Filed: | 04 Feb 2021 (4 years ago) |
| Document Number: | P06000072540 |
| FEI/EIN Number | 205066082 |
| Address: | 12791 World Plaza Lane, Bldg 89, FORT MYERS, FL, 33907, US |
| Mail Address: | 8430 BELLE MEADE DRIVE, FORT MYERS, FL, 33908, US |
| ZIP code: | 33907 |
| County: | Lee |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1003028119 | 2007-05-03 | 2024-02-05 | 8430 BELLE MEADE DR, FORT MYERS, FL, 339086009, US | 12791 WORLD PLAZA LN BLDG 89, FORT MYERS, FL, 339073989, US | |||||||||||||||||||||||||||||
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| Phone | +1 239-826-7903 |
| Fax | 2396454777 |
| Phone | +1 239-829-5494 |
Authorized person
| Name | BRENDA K SLUDER |
| Role | OFFICE BILLING ADMINISTRATOR |
| Phone | 2398876004 |
Taxonomy
| Taxonomy Code | 103TC0700X - Clinical Psychologist |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS FLORIDA |
| Number | 74129 |
| State | FL |
| Issuer | BCBS-FL BLUE |
| Number | NJ5TQ |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SPENCER NANCY TDr. | Agent | 8430 BELLE MEADE DRIVE, FORT MYERS, FL, 33908 |
| Name | Role | Address |
|---|---|---|
| SPENCER NANCY T | PSYD | 8430 BELLE MEADE DRIVE, FORT MYERS, FL, 33908 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| NAME CHANGE AMENDMENT | 2021-02-04 | FORT MYERS PSYCHOLOGY, PA | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2020-06-07 | 12791 World Plaza Lane, Bldg 89, FORT MYERS, FL 33907 | No data |
| CHANGE OF MAILING ADDRESS | 2015-02-22 | 12791 World Plaza Lane, Bldg 89, FORT MYERS, FL 33907 | No data |
| REGISTERED AGENT NAME CHANGED | 2015-02-22 | SPENCER, NANCY T, Dr. | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2015-02-22 | 8430 BELLE MEADE DRIVE, FORT MYERS, FL 33908 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-12 |
| ANNUAL REPORT | 2023-01-22 |
| ANNUAL REPORT | 2022-03-11 |
| Name Change | 2021-02-04 |
| ANNUAL REPORT | 2021-02-02 |
| ANNUAL REPORT | 2020-06-07 |
| ANNUAL REPORT | 2019-04-05 |
| ANNUAL REPORT | 2018-03-12 |
| ANNUAL REPORT | 2017-01-09 |
| ANNUAL REPORT | 2016-02-15 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
