Provider Demographics
NPI:1609609320
Name:ULSTAD, HEATHER MARIE (MS MERP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:ULSTAD
Suffix:
Gender:F
Credentials:MS MERP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 CENTRAL PARK BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4926
Mailing Address - Country:US
Mailing Address - Phone:540-602-2545
Mailing Address - Fax:
Practice Address - Street 1:1380 CENTRAL PARK BLVD STE 204
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4926
Practice Address - Country:US
Practice Address - Phone:540-602-2545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704017237101YM0800X, 101Y00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst