Provider Demographics
NPI:1932110863
Name:SOUPISET, KEVYN L (PT)
Entity Type:Individual
Prefix:MR
First Name:KEVYN
Middle Name:L
Last Name:SOUPISET
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-9255
Mailing Address - Country:US
Mailing Address - Phone:620-285-6011
Mailing Address - Fax:620-285-6012
Practice Address - Street 1:117 W 6TH ST
Practice Address - Street 2:
Practice Address - City:LARNED
Practice Address - State:KS
Practice Address - Zip Code:67550-3045
Practice Address - Country:US
Practice Address - Phone:620-285-6011
Practice Address - Fax:620-285-6012
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200547290AMedicaid
KS176565Medicare Oscar/Certification