Healthcare Provider Details

I. General information

NPI: 1427308618
Provider Name (Legal Business Name): ALIDA NOVARESE GAGE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 POPLAR AVE STE 1632
MEMPHIS TN
38157-1632
US

IV. Provider business mailing address

PO BOX 269
ELLENDALE TN
38029
US

V. Phone/Fax

Practice location:
  • Phone: 901-201-9432
  • Fax:
Mailing address:
  • Phone: 901-216-4354
  • Fax: 888-519-3386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3207
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: