MEDICARE: DR. ELISA LACONICH, PH.D., PLLC

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
1	103G00000X	Clinical Neuropsychologist

General Provider Information

NPI Number	:	1598341307
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. ELISA LACONICH, PH.D., PLLC

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 STE 101
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-2615
Country	:	US
Telephone Number	:	904-374-4276
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL NEUROPSYCHOLOGIST
Name	:	DR. ALICIA ELISA AYALA LACONICH
Credential	:	PH.D
Telephone Number	:	561-577-3402

Provider Enumeration Date	:	03/22/2021
Last Update Date	:	03/22/2022

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