Provider Demographics
NPI:1457474702
Name:TRACE, BOBBETTE LOU (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BOBBETTE
Middle Name:LOU
Last Name:TRACE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2529 LENA CT
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:NV
Mailing Address - Zip Code:89423-7021
Mailing Address - Country:US
Mailing Address - Phone:814-795-1635
Mailing Address - Fax:
Practice Address - Street 1:2529 LENA CT
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:NV
Practice Address - Zip Code:89423-7021
Practice Address - Country:US
Practice Address - Phone:814-795-1635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL007402235Z00000X
NVSP-1366235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001444546OtherHIGHMARK BLUE CROSS
PA1010232180002Medicaid