Healthcare Provider Details

I. General information

NPI: 1023120276
Provider Name (Legal Business Name): GREGORY LEO GULLICKSON PH D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWKINS DR
IOWA CITY IA
52242-1009
US

IV. Provider business mailing address

200 HAWKINS DR
IOWA CITY IA
52242-1009
US

V. Phone/Fax

Practice location:
  • Phone: 319-356-4200
  • Fax: 319-353-8383
Mailing address:
  • Phone: 319-356-4200
  • Fax: 319-353-8383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number00314
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number00314
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number00772
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number00314
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: