Provider Demographics
NPI:1669419610
Name:SOUKUP, KELLY J (PT)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:J
Last Name:SOUKUP
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:19052 INMAN TRL
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-4701
Mailing Address - Country:US
Mailing Address - Phone:952-469-6925
Mailing Address - Fax:
Practice Address - Street 1:1000 W 140TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4480
Practice Address - Country:US
Practice Address - Phone:952-808-3052
Practice Address - Fax:952-846-2202
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7269225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN210K0SOOtherBLUECROSS BLUESHEILD
MN011698000Medicaid
MN6404216OtherMEDICA
MNHP39430OtherHEALTHPARTNERS
MN6404216OtherMEDICA