Healthcare Provider Details

I. General information

NPI: 1043721558
Provider Name (Legal Business Name): BELINDA MAE LICEA MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 KINGSHIGHWAY ST STE 5
ROLLA MO
65401-2981
US

IV. Provider business mailing address

PO BOX 459
FARMINGTON MO
63640-0459
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-8511
  • Fax:
Mailing address:
  • Phone: 573-756-5749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number21619189
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: