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General NPI Number Information
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NPI Number | 1598341307
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Entity Type | Organization
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Legal Business Name | DR. ELISA LACONICH, PH.D., PLLC
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Dates
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Enumeration Date | 03/22/2021
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Last Update Date | 03/22/2022
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Provider Practice Location Address
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Address Line | 12574 FLAGLER CENTER BLVD STE 101
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City | JACKSONVILLE
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State | FL
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Zip | 32258-2615
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Country | US
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Telephone | 904-374-4276
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Fax |
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Provider Business Mailing Address
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Address Line | 12574 FLAGLER CENTER BLVD STE 101
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City | JACKSONVILLE
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State | FL
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Zip | 32258-2615
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CLINICAL NEUROPSYCHOLOGIST
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Name | DR. ALICIA ELISA AYALA LACONICH
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Credential | PH.D
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Telephone | 561-577-3402
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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