Healthcare Provider Details

I. General information

NPI: 1669419610
Provider Name (Legal Business Name): KELLY J SOUKUP PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W 140TH ST SUITE 202
BURNSVILLE MN
55337-4480
US

IV. Provider business mailing address

19052 INMAN TRL
LAKEVILLE MN
55044-4701
US

V. Phone/Fax

Practice location:
  • Phone: 952-808-3052
  • Fax: 952-846-2202
Mailing address:
  • Phone: 952-469-6925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7269
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: