Provider Demographics
NPI:1376699314
Name:SOUKUP, BETSY M (PTA)
Entity type:Individual
Prefix:MRS
First Name:BETSY
Middle Name:M
Last Name:SOUKUP
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 OAK ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901
Mailing Address - Country:US
Mailing Address - Phone:920-231-5492
Mailing Address - Fax:920-233-7352
Practice Address - Street 1:725 BUTLER AVENUE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-0010
Practice Address - Country:US
Practice Address - Phone:920-235-5100
Practice Address - Fax:920-233-7352
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI714019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40159400Medicaid