Provider Demographics
NPI:1598162208
Name:TRACE, MITCH (HIS)
Entity Type:Individual
Prefix:
First Name:MITCH
Middle Name:
Last Name:TRACE
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1887 LITITZ PIKE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-6516
Mailing Address - Country:US
Mailing Address - Phone:717-560-5023
Mailing Address - Fax:
Practice Address - Street 1:1887 LITITZ PIKE
Practice Address - Street 2:SUITE 2
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-6516
Practice Address - Country:US
Practice Address - Phone:717-560-5023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAFO3502237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist