Provider Demographics
NPI:1003035452
Name:ISETTA, VANESSA DIANE (PSYD)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:DIANE
Last Name:ISETTA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:VANESSA
Other - Middle Name:DIANE
Other - Last Name:BRUSAVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:2309 PACIFIC COAST HWY STE 207
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2753
Mailing Address - Country:US
Mailing Address - Phone:310-980-7352
Mailing Address - Fax:
Practice Address - Street 1:2309 PACIFIC COAST HWY
Practice Address - Street 2:SUITE #207
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2751
Practice Address - Country:US
Practice Address - Phone:310-980-7352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20941103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007302Medicaid
CACB24537OtherLA DMH PROVIDER