Healthcare Provider Details

I. General information

NPI: 1710626239
Provider Name (Legal Business Name): GREGORY PAUL ULLSTROM L..P..C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 W WASHINGTON AVE
MADISON WI
53703-2718
US

IV. Provider business mailing address

4800 N SCOTTSDALE RD STE 2500
SCOTTSDALE AZ
85251-7630
US

V. Phone/Fax

Practice location:
  • Phone: 262-999-3495
  • Fax:
Mailing address:
  • Phone: 262-999-3495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19509-130
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7001-226
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11073-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: