Individual
MR. KELLY J SOUKUP
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
1000 W 140TH ST, SUITE 202, BURNSVILLE, MN 55337-4480
(952) 808-3052
(952) 846-2202
Mailing address
19052 INMAN TRL, LAKEVILLE, MN 55044-4701
(952) 469-6925
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
7269
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
011698000
—
MN
01
—
210K0SO
BLUECROSS BLUESHEILD
MN
01
—
6404216
MEDICA
MN
01
—
HP39430
HEALTHPARTNERS
MN
Enumeration date
05/31/2006
Last updated
04/20/2011
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