Provider Demographics
NPI:1932243011
Name:MANETTA, BREA ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BREA
Middle Name:ANN
Last Name:MANETTA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 OLD TOWN SQ
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-2471
Mailing Address - Country:US
Mailing Address - Phone:970-391-0629
Mailing Address - Fax:970-482-0251
Practice Address - Street 1:19 OLD TOWN SQ
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-2471
Practice Address - Country:US
Practice Address - Phone:970-391-0629
Practice Address - Fax:970-482-0251
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2568103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO018336OtherVALUE OPTIONS
CO2270399OtherCIGNA
COMA658563OtherBLUE CROSS
CO01707353Medicaid
CO7079467OtherAETNA
CO2270399OtherCIGNA