Provider Demographics
NPI:1710626239
Name:ULLSTROM, GREGORY PAUL (LPC-IT, SAC-IT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
Last Name:ULLSTROM
Suffix:
Gender:M
Credentials:LPC-IT, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 ROCKEFELLER LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-7860
Mailing Address - Country:US
Mailing Address - Phone:608-417-8165
Mailing Address - Fax:
Practice Address - Street 1:1015 GAMMON LN
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-2210
Practice Address - Country:US
Practice Address - Phone:608-417-8144
Practice Address - Fax:608-417-8145
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19509-130101YA0400X
WI7001-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)