Provider Demographics
NPI:1063551513
Name:JOHNSON-DUNLAP, CECELIA (DO)
Entity type:Individual
Prefix:
First Name:CECELIA
Middle Name:
Last Name:JOHNSON-DUNLAP
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:
Mailing Address - City:HAVERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19041-0003
Mailing Address - Country:US
Mailing Address - Phone:610-642-2923
Mailing Address - Fax:
Practice Address - Street 1:119 COULTER AVE
Practice Address - Street 2:SUITES 145-155
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-2427
Practice Address - Country:US
Practice Address - Phone:610-642-2923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009838L174400000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1766435Medicaid
PA030824Medicare ID - Type UnspecifiedMEDICARE
PAH02324Medicare UPIN