MR. EMILIO LICEA III PSYD
NPI 1336496710
Psychologist - Clinical in Sebastopol, CA

Q: What is Emilio Licea's NPI number?

The NPI number for Emilio Licea is 1336496710. It was assigned to this individual provider in the NPPES registry on August 5, 2012.

Q: What is Emilio Licea's specialty?

The primary specialty registered for this NPI is Psychologist, specializing in Clinical, with taxonomy code 103TC0700X.

Q: When was this NPI record last updated?

The NPPES record for Emilio Licea was last updated on December 30, 2021. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 4 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.

Active since August 05, 2012PECOS Enrolled

652 PETALUMA AVE, SEBASTOPOL, CA 95472(707) 823-3166(707) 869-8170 Get Directions Write a Review

NPPES record last updated: December 30, 2021. Verified against the NPPES registry weekly; last sync: October 18, 2026.

Record update history: Dec 30, 2021, Dec 20, 2018 (2 updates tracked since 2018).

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About Mr. Emilio Licea Iii Psyd NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

MR. EMILIO LICEA III PSYD (NPI 1336496710) is an individual clinical provider in Sebastopol, California, licensed in California (PSY29447) and active in the NPI registry since August 2012. He is enrolled in Medicare PECOS.

NPPES Registry Identity

NPI1336496710

Entity TypeIndividualMale

Primary Taxonomy103TC0700X

Provider Legal NameMR. EMILIO LICEA IIICredential: PSYD

Location Address652 PETALUMA AVESebastopol, CA 95472-4256

Mailing AddressPo Box 1449Guerneville, CA 95446-1449 · (707) 869-5977 · Fax (707) 869-5976

Phone(707) 823-3166

Fax(707) 869-8170

Sole ProprietorNo

Enumeration DateAugust 5, 2012

Last NPPES UpdateDecember 30, 20212 updates tracked since enumeration

✔ NPI 1336496710 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyPsychologist · ClinicalBehavioral Health & Social Service Providers

Taxonomy Code103TC0700X

License✔ Licensed in CA · PSY29447

Definition

A psychologist who provides continuing and comprehensive mental and behavioral health care for individuals and families; consultation to agencies and communities; training, education and supervision; and research-based practice. It is a specialty in breadth -- one that is broadly inclusive of severe psychopathology -- and marked by comprehensiveness and integration of knowledge and skill from a broad array of disciplines within and outside of psychology proper. The scope of clinical psychology encompasses all ages, multiple diversities and varied systems.

652 PETALUMA AVE, Sebastopol, CA 95472

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Medicare Participation & PECOS CMS

Medicare enrollment, assignment, billing reassignment, and ordering and referring status from CMS.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Mr. Emilio Licea Iii Psyd is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment– Home Health Agency– Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.

Medicare Billing Reassignment

Medicare enrollment records show Emilio Licea reassigns Medicare billing to 1 organization. The organization bills Medicare for the services this provider delivers there.

Permanente Medical Group Inc

36 mi

Internal Medicine

975 SERENO DRIVE
Vallejo, CA 94589

Reassigned Medicare billing, California enrollment
20,078 clinicians in this Medicare group

NPI 1336222397 (707) 651-1000

Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Physician Visit Costs CMS claims · ZIP area

Typical Medicare office-visit costs in the 95472 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.

New Patient

$187.01 typical visit price

range $63.04 – $187.01

Typical copayment $46.75 (range $15.76 – $46.75)

Most-billed visit code 99205

Established Patient

$109.88 typical visit price

range $21.02 – $153.40

Typical copayment $27.47 (range $5.25 – $38.35)

Most-billed visit code 99214

Amounts reflect what Medicare beneficiaries in this ZIP area are typically charged for office visits. Patients with other coverage should check their individual plans.

Other Providers at the Same Location NPPES 17

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

DR. JAMES ARTHUR LOWY MD

Family Medicine

652 PETALUMA AVE, SUITE F
SEBASTOPOL, CA 95472

Sonoma County (707) 823-2334

PRIMA MEDICAL FOUNDATION SEBASTOPOL

Clinic/Center (Multi-Specialty)

652 PETALUMA AVE, SUITE H
SEBASTOPOL, CA 95472

Sonoma County (707) 823-7616

NORTHERN CALIFORNIA MEDICAL ASSOC INC

Internal Medicine (Cardiovascular Disease)

652 PETALUMA AVE, STE E
SEBASTOPOL, CA 95472

Sonoma County (707) 573-6166

MAYA LOPEZ LCSW

Social Worker (Clinical)

652 PETALUMA AVE
SEBASTOPOL, CA 95472

Sonoma County (707) 216-0548

DR. HOPE ANITA BECKLUND MD

Family Medicine

652 PETALUMA AVE, SUITE F
SEBASTOPOL, CA 95472

Sonoma County (707) 823-2334

SUTTER MEDICAL GROUP OF THE REDWOODS

Family Medicine

652 PETALUMA AVE, SUITE F
SEBASTOPOL, CA 95472

Sonoma County (707) 823-2334

MS. SUZANNE YEOMANS LCSW

Social Worker (Clinical)

652 PETALUMA AVE
SEBASTOPOL, CA 95472

Sonoma County (707) 823-3166

VALERIE STONE FNP-C

Nurse Practitioner (Family)

652 PETALUMA AVE
SEBASTOPOL, CA 95472

Sonoma County (707) 823-3166

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Emilio Licea's NPI number?

The NPI number for Emilio Licea is 1336496710. It was assigned to this individual provider in the NPPES registry on August 5, 2012.

Where is Emilio Licea located?

Emilio Licea practices at 652 Petaluma Ave, Sebastopol, CA 95472. The listed phone number is (707) 823-3166.

What is Emilio Licea's specialty?

The primary specialty registered for this NPI is Psychologist, specializing in Clinical, with taxonomy code 103TC0700X.

Is Emilio Licea enrolled in Medicare?

Yes. Emilio Licea is registered in the Medicare PECOS enrollment system.

Which organization bills Medicare for Emilio Licea's services?

According to the CMS Revalidation Reassignment List (October 2026 release), Emilio Licea reassigns Medicare benefits to Permanente Medical Group Inc (Vallejo, CA). The reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for Emilio Licea's services. Reassignment records can lag staffing changes; confirm current arrangements with the organization.

When was this NPI record last updated?

The NPPES record for Emilio Licea was last updated on December 30, 2021. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 4 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.