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General NPI Number Information
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NPI Number | 1710626239
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Entity Type | Individual
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Provider Name | GREGORY PAUL ULLSTROM L..P..C.
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Gender | Male
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Dates
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Enumeration Date | 06/02/2022
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Last Update Date | 08/12/2025
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Provider Practice Location Address
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Address Line | 122 W WASHINGTON AVE
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City | MADISON
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State | WI
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Zip | 53703-2718
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Country | US
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Telephone | 262-999-3495
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Fax |
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Provider Business Mailing Address
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Address Line | 4800 N SCOTTSDALE RD STE 2500
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City | SCOTTSDALE
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State | AZ
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Zip | 85251-7630
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Country | US
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Telephone | 262-999-3495
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 19509-130
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 7001-226
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 11073-125
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License Number State | WI
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