Provider Demographics
NPI:1750074142
Name:SOUPAL, DEAN (MT)
Entity type:Individual
Prefix:MR
First Name:DEAN
Middle Name:
Last Name:SOUPAL
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 JUNIPER TRL
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-6503
Mailing Address - Country:US
Mailing Address - Phone:248-495-3220
Mailing Address - Fax:
Practice Address - Street 1:2155 W STATE ROUTE 89A STE 114
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-5445
Practice Address - Country:US
Practice Address - Phone:928-239-9706
Practice Address - Fax:928-239-9716
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-28698225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist