Provider Demographics
NPI:1316838733
Name:SHOUP, RAYMOND CHRISTOPHER (LICSW)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:CHRISTOPHER
Last Name:SHOUP
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 SOUTHHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4188
Mailing Address - Country:US
Mailing Address - Phone:507-458-1590
Mailing Address - Fax:
Practice Address - Street 1:614 SOUTHHAVEN DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4188
Practice Address - Country:US
Practice Address - Phone:507-458-1590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN314761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical