Provider Demographics
NPI:1760416101
Name:DONNELLY, GOSHA (PHD)
Entity Type:Individual
Prefix:DR
First Name:GOSHA
Middle Name:
Last Name:DONNELLY
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 1:11 BEAVER MEADOW ROAD
Mailing Address - Street 2:SUITE 4, OFFICE 2
Mailing Address - City:NORWICH
Mailing Address - State:VT
Mailing Address - Zip Code:05055
Mailing Address - Country:US
Mailing Address - Phone:802-649-2266
Mailing Address - Fax:
Practice Address - Street 1:11 BEAVER MEADOW ROAD
Practice Address - Street 2:SUITE 4, OFFICE 2
Practice Address - City:NORWICH
Practice Address - State:VT
Practice Address - Zip Code:05055
Practice Address - Country:US
Practice Address - Phone:802-649-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0480000708103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN 1837Medicaid
DO VN 1837Medicare ID - Type Unspecified