MR. EMILIO LICEA III (NPI# 1336496710) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1336496710 |
| Entity Type | Individual |
| Full Name | MR. EMILIO LICEA III |
| Credential | PSYD |
| Practice Address |
652 Petaluma Ave Sebastopol CA 95472-4256 |
| Mailing Address |
Po Box 1449 Guerneville CA 95446-1449 |
| Practice Telephone | 7078233166 |
| Practice Fax Number | 7078698170 |
| Mailing Telephone | 7078695977 |
| Mailing Fax Number | 7078695976 |
| Enumeration Date | 2012-08-05 |
| Last Update Date | 2018-12-20 |
| Gender Code | M |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 103TC0700X |
Psychologist Specialization: Clinical |
PSY29447 | CA | Behavioral Health & Social Service Providers |
| Street Address |
652 PETALUMA AVE |
| City | SEBASTOPOL |
| State | CA |
| Zip Code | 95472-4256 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1962401463 | Misty Michelle Zelk | Internal Medicine | 652 Petaluma Ave, Suite H, Sebastopol, CA 95472-4256 | 2005-07-18 |
| 1275016230 | Connie Alejandrina Moreno | Nurse Practitioner | 652 Petaluma Ave, Sebastopol, CA 95472-4256 | 2018-09-14 |
| 1114382751 | Shelleen E Denno Md Inc. | Internal Medicine | 652 Petaluma Ave, Suite D, Sebastopol, CA 95472-4256 | 2015-12-28 |
| 1861809501 | West County Health Centers, Inc. | Clinic/Center | 652 Petaluma Ave, Sebastopol, CA 95472-4256 | 2014-07-15 |
| 1902244528 | Prima Medical Foundation | General Practice | 652 Petaluma Ave, Suite H, Sebastopol, CA 95472-4256 | 2013-06-05 |
| 1154590958 | Prima Medical Foundation Sebastopol | Clinic/Center | 652 Petaluma Ave, Suite H, Sebastopol, CA 95472-4256 | 2008-02-26 |
| 1184845182 | Northern California Medical Assoc Inc | Internal Medicine | 652 Petaluma Ave, Ste E, Sebastopol, CA 95472-4266 | 2007-05-01 |
| 1871665471 | Scott Benstock | Dentist | 652 Petaluma Ave, Suite A, Sebastopol, CA 95472-4256 | 2006-11-15 |
| 1992889067 | Allan L. Bernstein | Psychiatry & Neurology | 652 Petaluma Ave, Suite H, Sebastopol, CA 95472-4256 | 2006-10-25 |
| 1497842835 | Sutter Medical Group of The Redwoods | Obstetrics & Gynecology | 652 Petaluma Ave, Suite F, Sebastopol, CA 95472-4256 | 2006-10-06 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1558916791 | Mellisa Nicole Elrod | Occupational Therapist | 1935 Gravenstein Hwy, Sebastopol, CA 95472 | 2019-08-05 |
| 1457820987 | Isabel Brooke Martinez | Acupuncturist | 961 Gravenstein Hwy South, # 100, Sebastopol, CA 95472 | 2018-11-14 |
| 1275025470 | Shahbano Syeda | Specialist/Technologist | 846/848 Gravenstein Hwy South, Sebastopol, CA 95472 | 2018-06-04 |
| 1467990812 | Mathew Metzgar | Marriage & Family Therapist | 1800 N. Gravenstein Hwy, Sebastopol, CA 95472 | 2017-02-06 |
| 1760939318 | Andrea Kirk | Psychologist | 876 Gravenstein Hwy S., Suite 6, Sebastopol, CA 95472 | 2016-09-01 |
| 1548629371 | Stacy Simons | Massage Therapist | 103 Morris St Ste V, Sebastopol, CA 95472 | 2016-02-22 |
| 1619341880 | Carol Schmid | Counselor | 1800 N, Gravenstein Hwy, Sebastopol, CA 95472 | 2015-11-25 |
| 1801273727 | Aaron Martinez | Specialist/Technologist | 7441 Witter Road, Sebastopol, CA 95472 | 2015-04-29 |
| 1699167049 | Nia Kaye | Marriage & Family Therapist | 130 Petaluma Ave Ste 2c, Sebastopol, CA 95472 | 2015-02-23 |
| 1497091383 | Caitlin Marie Kirkman | Midwife | 5611 Hessel Ave, Sebastopol, CA 95472 | 2012-12-20 |
| Find all providers in zip 95472 | ||||
| Taxonomy Code | 103TC0700X |
| Grouping | Behavioral Health & Social Service Providers |
| Classification | Psychologist |
| Specialization | Clinical |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1730591835 | Jonathan Gonick-hallows | Psychologist | 8380 Germone Rd, Sebastopol, CA 95472-4008 | 2014-05-22 |
| 1659512697 | James Leon Friedman | Psychologist | 4440 Belmont Dr, Sebastopol, CA 95472-6307 | 2009-03-22 |
| 1811174220 | Vipassana Christine Esbjorn | Psychologist | 7151 Wilton Ave, Ste 201, Sebastopol, CA 95472-3756 | 2008-01-28 |
| 1710184593 | Russell Schreiber | Psychologist | 11000 Falstaff Rd, Sebastopol, CA 95472-9114 | 2007-06-27 |
| 1497964738 | Charles Noma Harris | Psychologist | 4815 Thomas Rd, Sebastopol, CA 95472-9764 | 2007-05-22 |
| 1245442722 | Thea Goldstine | Psychologist | 171 N. High St., Sebastopol, CA 95472 | 2007-05-04 |
| 1083777965 | Richard P Caruso | Psychologist | 7470 Kennedy Rd, Sebastopol, CA 95472-5420 | 2006-12-19 |
| 1023179322 | Kenneth Hunter Crittenden | Psychologist | 501 Swain Ave, Sebastopol, CA 95472-4339 | 2006-12-12 |
| 1043384720 | Anne M Pincus | Psychologist | 1070 Gravenstein Hwy S., Suite 130, Sebastopol, CA 95472 | 2006-11-17 |
| 1518053578 | June Ann Gordon | Psychologist | 1741 Gravenstein Hwy S, Sebastopol, CA 95472-4838 | 2006-10-05 |
| Find all providers in SEBASTOPOL | ||||
| City | SEBASTOPOL |
| Zip Code | 95472 |
Please comment or provide details below to improve the information on MR. EMILIO LICEA III.
| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.