Provider Demographics
NPI:1427308618
Name:GAGE, ALIDA NOVARESE (PHD)
Entity type:Individual
Prefix:
First Name:ALIDA
Middle Name:NOVARESE
Last Name:GAGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:ELLENDALE
Mailing Address - State:TN
Mailing Address - Zip Code:38029
Mailing Address - Country:US
Mailing Address - Phone:901-216-4354
Mailing Address - Fax:888-519-3386
Practice Address - Street 1:5050 POPLAR AVE
Practice Address - Street 2:STE 1632
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38157-1632
Practice Address - Country:US
Practice Address - Phone:901-201-9432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN3207103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program