Provider Demographics
NPI:1457688483
Name:LANDERS, ELISHA GAYLE (MED)
Entity Type:Individual
Prefix:MISS
First Name:ELISHA
Middle Name:GAYLE
Last Name:LANDERS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13703 RICHMOND PARK DR N APT 2306
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-4298
Mailing Address - Country:US
Mailing Address - Phone:904-294-6153
Mailing Address - Fax:
Practice Address - Street 1:10175 FORTUNE PKWY UNIT 903
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6755
Practice Address - Country:US
Practice Address - Phone:904-538-0713
Practice Address - Fax:904-538-0714
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool