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NPI Code Detail

MEDICARE: DR. ALICIA ELISA AYALA LACONICH PH.D IN PSYCHOLOGY

MEDICARE: DR. ALICIA ELISA AYALA LACONICH PH.D IN PSYCHOLOGY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103G00000XClinical NeuropsychologistPY10781FL
2103TC0700XClinical PsychologistPY10781FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1376138495
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ALICIA ELISA AYALA LACONICH PH.D IN PSYCHOLOGY
Provider Business Mailing Address
First Line : 12574 FLAGLER CENTER BLVD STE 101
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32258-2615
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 12574 FLAGLER CENTER BLVD
Second Line : STE 101
City : JACKSONVILLE
State : FL
Zip : 32258-2615
Country : US
Telephone Number : 904-374-4276
Fax Number : 888-495-1508
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/02/2021
Last Update Date : 09/10/2025

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