Provider Demographics
NPI:1245712504
Name:MITCHELL, TRACY JEAN
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:JEAN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 WRIGHTS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-8946
Mailing Address - Country:US
Mailing Address - Phone:276-322-5450
Mailing Address - Fax:
Practice Address - Street 1:1200 MERCER ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-425-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-1902235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist