| Entity Name: | ADULT & CHILD COUNSELING AND PSYCHIATRIC CENTER, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 12 Jan 1998 (27 years ago) |
| Document Number: | P98000004035 |
| FEI/EIN Number | 593488333 |
| Address: | 5545 N. Wickham Road, Melbourne, FL, 32940, US |
| Mail Address: | 5545 N. Wickham Road, Melbourne, FL, 32940, US |
| ZIP code: | 32940 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1629034996 | 2006-04-25 | 2014-04-17 | 5545 N WICKHAM RD, SUITE 110, MELBOURNE, FL, 329407323, US | 5545 N WICKHAM RD, SUITE 110, MELBOURNE, FL, 329407323, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 321-779-9838 |
| Fax | 3217794502 |
Authorized person
| Name | DR. VIJAYKUMAR R BHUJANG |
| Role | CEO |
| Phone | 3217799838 |
Taxonomy
| Taxonomy Code | 101YM0800X - Mental Health Counselor |
| Is Primary | No |
| Taxonomy Code | 104100000X - Social Worker |
| License Number | SW3652 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 104100000X - Social Worker |
| License Number | SW3614 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2084P0800X - Psychiatry Physician |
| License Number | ME50534 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 2084P0800X - Psychiatry Physician |
| License Number | ME40362 |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 253817200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Eaton James VLMHC | Agent | 5545 N. Wickham Road, Melbourne, FL, 32940 |
| Name | Role | Address |
|---|---|---|
| EATON JAMES V | Manager | 5545 N Wickham Road, Melbourne, FL, 32940 |
| PATRICIA GAUME D | Manager | 5545 N. Wickham Road, Melbourne, FL, 32940 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2024-03-05 | Eaton, James V, LMHC | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2014-04-09 | 5545 N. Wickham Road, Suite 110, Melbourne, FL 32940 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2014-04-09 | 5545 N. Wickham Road, 110, Melbourne, FL 32940 | No data |
| CHANGE OF MAILING ADDRESS | 2013-02-14 | 5545 N. Wickham Road, Suite 110, Melbourne, FL 32940 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-05 |
| ANNUAL REPORT | 2023-01-26 |
| ANNUAL REPORT | 2022-02-03 |
| ANNUAL REPORT | 2021-02-03 |
| ANNUAL REPORT | 2020-01-20 |
| ANNUAL REPORT | 2019-02-18 |
| ANNUAL REPORT | 2018-01-20 |
| ANNUAL REPORT | 2017-02-01 |
| ANNUAL REPORT | 2016-02-29 |
| ANNUAL REPORT | 2015-02-03 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
