MEDICARE: HEATHER MARIE ULSTAD MS MERP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	0704017237	VA
2	103K00000X	Behavior Analyst
3	101Y00000X	Counselor	0704017237	VA

General Provider Information

NPI Number	:	1609609320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER MARIE ULSTAD MS MERP

Provider Business Mailing Address
First Line	:	1380 CENTRAL PARK BLVD STE 204
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-4926
Country	:	US
Telephone Number	:	540-602-2545
Fax Number	:

Provider Business Practice Location Address
First Line	:	1380 CENTRAL PARK BLVD STE 204
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-4926
Country	:	US
Telephone Number	:	540-602-2545
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2024
Last Update Date	:	08/20/2024

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