Provider Information for 1710626239
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GREGORY PAUL ULLSTROM LPC, SAC-IT
Sex: Male
NPI: 1710626239
Last Updated: 2024-06-03
Certification Date: 2024-06-03
Certification Date: 2024-06-03
Details
| Name | Value | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1710626239 | ||||||||||||||||
| Enumeration Date | 2022-06-02 | ||||||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||||||
| Sole Proprietor | NO | ||||||||||||||||
| Status | Active | ||||||||||||||||
| Mailing Address | 933 ROCKEFELLER LN MADISON, WI 53704-7860 United States Phone: 608-417-8165 | Fax: | ||||||||||||||||
| Primary Practice Address | 1015 GAMMON LN MADISON, WI 53719-2210 United States Phone: 608-417-8144 | Fax:608-417-8145 | ||||||||||||||||
| Secondary Practice Address(es) | 933 ROCKEFELLER LN | ||||||||||||||||
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