Provider Demographics
NPI:1730744061
Name:SOUKUP, TARYNE (CT)
Entity type:Individual
Prefix:
First Name:TARYNE
Middle Name:
Last Name:SOUKUP
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT 781629
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1629
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:614-355-2220
Practice Address - Street 1:495 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5679
Practice Address - Country:US
Practice Address - Phone:614-355-8055
Practice Address - Fax:614-355-8056
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
C.1901634-TRNE101YM0800X
OHC2002690101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid