=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043721558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BELINDA MAE LICEA MA, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2017
-----------------------------------------------------
Last Update Date | 01/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1051 KINGSHIGHWAY ST STE 5
-----------------------------------------------------
City | ROLLA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65401-2981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-364-8511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 459
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63640-0459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-756-5749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 21619189
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------