Provider Demographics
NPI:1598341307
Name:DR. ELISA LACONICH, PH.D., PLLC
Entity Type:Organization
Organization Name:DR. ELISA LACONICH, PH.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:ELISA
Authorized Official - Last Name:AYALA LACONICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:561-577-3402
Mailing Address - Street 1:12574 FLAGLER CENTER BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-2615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12574 FLAGLER CENTER BLVD STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-2615
Practice Address - Country:US
Practice Address - Phone:904-374-4276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty