Provider Demographics
NPI:1992923817
Name:MITCHELL, TRACEY WALLACE (LPTA)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:WALLACE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 JONES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-6078
Mailing Address - Country:US
Mailing Address - Phone:434-476-9630
Mailing Address - Fax:
Practice Address - Street 1:103 ROSEHILL DR
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-4843
Practice Address - Country:US
Practice Address - Phone:434-572-4906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001473225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant