Provider Demographics
NPI:1336496710
Name:LICEA, EMILIO III (PSYD)
Entity Type:Individual
Prefix:MR
First Name:EMILIO
Middle Name:
Last Name:LICEA
Suffix:III
Gender:M
Credentials:PSYD
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 1449
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446-1449
Mailing Address - Country:US
Mailing Address - Phone:707-869-5977
Mailing Address - Fax:707-869-5976
Practice Address - Street 1:652 PETALUMA AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4256
Practice Address - Country:US
Practice Address - Phone:707-823-3166
Practice Address - Fax:707-869-8170
Is Sole Proprietor?:No
Enumeration Date:2012-08-05
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29447103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical