Provider Demographics
NPI:1649087792
Name:MITCHELL, TRACY D
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:D
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 1:3127 MCKINNEY DR
Mailing Address - Street 2:
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568-3649
Mailing Address - Country:US
Mailing Address - Phone:281-372-9639
Mailing Address - Fax:
Practice Address - Street 1:3127 MCKINNEY DR
Practice Address - Street 2:
Practice Address - City:LA MARQUE
Practice Address - State:TX
Practice Address - Zip Code:77568-3649
Practice Address - Country:US
Practice Address - Phone:281-372-9639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76A33366AA1E78C202K00000X
TXNA0008786457376K00000X
TXRBT24-382288106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No376K00000XNursing Service Related ProvidersNurse's Aide