| Entity Name: | PSYCHIATRY WELLNESS CENTER PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Inactive |
| Date Filed: | 20 Mar 2020 (5 years ago) |
| Date of dissolution: | 28 Nov 2022 (2 years ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 28 Nov 2022 (2 years ago) |
| Document Number: | P20000025269 |
| FEI/EIN Number | 85-0517290 |
| Address: | 6801 LAKE WORTH RD, SUITE 201-202, GREENACRES, FL 33467 |
| Mail Address: | 6801 LAKE WORTH RD, SUITE 201-202, GREENACRES, FL 33467 |
| ZIP code: | 33467 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1386271849 | 2020-03-25 | 2022-09-20 | 6801 LAKE WORTH RD STE 213-214, LAKE WORTH, FL, 334672955, US | 6801 LAKE WORTH RD STE 213-214, GREENACRES, FL, 334672955, US | |||||||||||||||||||||
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| Phone | +1 561-444-2351 |
| Fax | 5614697089 |
Authorized person
| Name | JANELL LYNN TABORA |
| Role | DIRECTOR |
| Phone | 6026969272 |
Taxonomy
| Taxonomy Code | 2084P0800X - Psychiatry Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 107183900 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Davis, Ebony Renae | Agent | 6801 LAKE WORTH RD, SUITE 201-202, GREENACRES, FL 33467 |
| Name | Role | Address |
|---|---|---|
| TABORA, JANELL | Vice President | 6801 LAKE WORTH RD SUITE 213-214, GREENACRES, FL 33467 |
| Name | Role | Address |
|---|---|---|
| DAVIS, EBONY Renae | President | 6801 LAKE WORTH RD SUITE 213-214, GREENACRES, FL 33467 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2022-11-28 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2022-04-29 | 6801 LAKE WORTH RD, SUITE 201-202, GREENACRES, FL 33467 | No data |
| CHANGE OF MAILING ADDRESS | 2022-04-29 | 6801 LAKE WORTH RD, SUITE 201-202, GREENACRES, FL 33467 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2022-04-29 | 6801 LAKE WORTH RD, SUITE 201-202, GREENACRES, FL 33467 | No data |
| REGISTERED AGENT NAME CHANGED | 2021-03-30 | Davis, Ebony Renae | No data |
| AMENDMENT | 2020-05-18 | No data | No data |
| Name | Date |
|---|---|
| VOLUNTARY DISSOLUTION | 2022-11-28 |
| ANNUAL REPORT | 2022-04-29 |
| ANNUAL REPORT | 2021-03-30 |
| Amendment | 2020-05-18 |
| Domestic Profit | 2020-03-20 |
Date of last update: 16 Jan 2025
Sources: Florida Department of State
