Provider Demographics
NPI:1942075171
Name:SOUPISET, MADISON (DPT, PT)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:SOUPISET
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5706 FLAGLER DR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-2959
Mailing Address - Country:US
Mailing Address - Phone:319-600-2200
Mailing Address - Fax:
Practice Address - Street 1:12825 MINNIEVILLE RD STE 203
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-3602
Practice Address - Country:US
Practice Address - Phone:703-647-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
VA2305216272225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist