Provider Demographics
NPI:1861688442
Name:SOUKUP, FRED (LPT)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:
Last Name:SOUKUP
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 WRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4441
Mailing Address - Country:US
Mailing Address - Phone:218-825-0913
Mailing Address - Fax:218-828-1947
Practice Address - Street 1:1919 S 7TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4523
Practice Address - Country:US
Practice Address - Phone:218-825-0913
Practice Address - Fax:218-828-1947
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5456225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist