Healthcare Provider Details

I. General information

NPI: 1760416101
Provider Name (Legal Business Name): GOSHA DONNELLY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

11 BEAVER MEADOW ROAD SUITE 4, OFFICE 2
NORWICH VT
05055
US

IV. Provider business mailing address

11 BEAVER MEADOW ROAD SUITE 4, OFFICE 2
NORWICH VT
05055
US

V. Phone/Fax

Practice location:
  • Phone: 802-649-2266
  • Fax:
Mailing address:
  • Phone: 802-649-2266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0480000708
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: