Individual
MR. EMILIO LICEA III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PSYD
Contact information
Practice address
652 PETALUMA AVE, SEBASTOPOL, CA 95472-4256
(707) 823-3166
(707) 869-8170
Mailing address
PO BOX 1449, GUERNEVILLE, CA 95446-1449
(707) 869-5977
(707) 869-5976
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
PSY29447
CA
Other
Enumeration date
08/05/2012
Last updated
12/30/2021
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