Healthcare Provider Details

I. General information

NPI: 1639262447
Provider Name (Legal Business Name): SHOSHANNA S SHELLEY ED.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BEAVER MEADOW ROAD
NORWICH VT
05055
US

IV. Provider business mailing address

PO BOX 4
NORWICH VT
05055
US

V. Phone/Fax

Practice location:
  • Phone: 802-649-1123
  • Fax: 802-649-1141
Mailing address:
  • Phone: 802-649-1123
  • Fax: 802-649-1141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number401
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3054
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: