Provider Demographics
NPI:1639262447
Name:SHELLEY, SHOSHANNA S (EDD)
Entity type:Individual
Prefix:DR
First Name:SHOSHANNA
Middle Name:S
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:VT
Mailing Address - Zip Code:05055
Mailing Address - Country:US
Mailing Address - Phone:802-649-1123
Mailing Address - Fax:802-649-1141
Practice Address - Street 1:11 BEAVER MEADOW ROAD
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:VT
Practice Address - Zip Code:05055
Practice Address - Country:US
Practice Address - Phone:802-649-1123
Practice Address - Fax:802-649-1141
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT401103T00000X
MA3054103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN0587Medicaid
VTVN2398Medicare ID - Type Unspecified