Provider Demographics
NPI:1538367230
Name:MITCHELL, TRACIE LEA (SLP)
Entity type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:LEA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 DOCKS CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:KENOVA
Mailing Address - State:WV
Mailing Address - Zip Code:25530
Mailing Address - Country:US
Mailing Address - Phone:304-453-5055
Mailing Address - Fax:
Practice Address - Street 1:2312 DOCKS CREEK RD
Practice Address - Street 2:
Practice Address - City:KENOVA
Practice Address - State:WV
Practice Address - Zip Code:25530-9747
Practice Address - Country:US
Practice Address - Phone:304-453-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-2492235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist