Provider Demographics
NPI:1508025842
Name:PETIT DE MANGE, NINA (PSYD)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:PETIT DE MANGE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 131653
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92013-1653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3150 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2110
Practice Address - Country:US
Practice Address - Phone:760-276-4606
Practice Address - Fax:760-276-4605
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical