| Entity Name: | MICHAEL PLASENCIA, PSYD PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 22 Aug 2019 (5 years ago) |
| Document Number: | P19000067336 |
| FEI/EIN Number | 84-3018163 |
| Address: | 10406 TAFT STREET, PEMBROKE PINES, FL 33026 |
| Mail Address: | 10406 TAFT STREET, PEMBROKE PINES, FL 33026 |
| ZIP code: | 33026 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1063050359 | 2019-12-17 | 2019-12-17 | 10406 TAFT ST, PEMBROKE PINES, FL, 330262819, US | 10406 TAFT ST, PEMBROKE PINES, FL, 330262819, US | |||||||||||||||||||||
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| Phone | +1 954-436-3880 |
| Fax | 9544363881 |
Authorized person
| Name | MICHAEL ANTHONY PLASENCIA |
| Role | PRESIDENT |
| Phone | 9545599201 |
Taxonomy
| Taxonomy Code | 103TC0700X - Clinical Psychologist |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 024003800 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| GONZALEZ, ODISA | Agent | 6251 NW 110TH TERRACE, HIALEAH, FL 33012 |
| Name | Role | Address |
|---|---|---|
| PLASENCIA, MICHAEL | President | 10406 TAFT STREET, PEMBROKE PINES, FL 33026 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-07 |
| ANNUAL REPORT | 2023-04-24 |
| ANNUAL REPORT | 2022-04-28 |
| ANNUAL REPORT | 2021-04-28 |
| ANNUAL REPORT | 2020-06-30 |
| Domestic Profit | 2019-08-22 |
Date of last update: 16 Jan 2025
Sources: Florida Department of State
