Provider Demographics
NPI:1376138495
Name:AYALA LACONICH, ALICIA ELISA (PHD IN PSYCHOLOGY)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:ELISA
Last Name:AYALA LACONICH
Suffix:
Gender:F
Credentials:PHD IN PSYCHOLOGY
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Mailing Address - Street 1:12574 FLAGLER CENTER BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-2615
Mailing Address - Country:US
Mailing Address - Phone:904-374-4276
Mailing Address - Fax:888-495-1508
Practice Address - Street 1:1301 PALM AVE STE 4A017
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8432
Practice Address - Country:US
Practice Address - Phone:904-376-3800
Practice Address - Fax:904-390-7395
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2024-02-08
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Provider Licenses
StateLicense IDTaxonomies
103TB0200X
FLPY10781103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical