Provider Demographics
NPI:1669207510
Name:MANETTA, ETIANNE CAMILLE (PSYD)
Entity type:Individual
Prefix:
First Name:ETIANNE
Middle Name:CAMILLE
Last Name:MANETTA
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 1:1350 COLUMBIA ST UNIT 402
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 COLUMBIA ST UNIT 402
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3455
Practice Address - Country:US
Practice Address - Phone:619-393-1447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY35217103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical