Provider Demographics
NPI:1750711719
Name:GOSCHA, SHELLY SUE (LCSW)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:SUE
Last Name:GOSCHA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 ASHLAND CT
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-7661
Mailing Address - Country:US
Mailing Address - Phone:785-766-1885
Mailing Address - Fax:916-235-5843
Practice Address - Street 1:5170 GOLDEN FOOTHILL PKWY
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9608
Practice Address - Country:US
Practice Address - Phone:785-766-1885
Practice Address - Fax:916-235-5843
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA802631041C0700X
KS19801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1750711719Medicaid