Healthcare Provider Details

I. General information

NPI: 1700708245
Provider Name (Legal Business Name): ELISA LAGE NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 MADRUGA AVE STE 510
CORAL GABLES FL
33146-3048
US

IV. Provider business mailing address

13655 SW 99TH ST
MIAMI FL
33186-2807
US

V. Phone/Fax

Practice location:
  • Phone: 786-452-9984
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS2028
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: