Provider Demographics
NPI:1821105818
Name:DUNLAP, SALLY M (PHD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:M
Last Name:DUNLAP
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 BROADWAY ST
Mailing Address - Street 2:STE 218
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-3743
Mailing Address - Country:US
Mailing Address - Phone:210-822-4022
Mailing Address - Fax:210-930-8986
Practice Address - Street 1:7201 BROADWAY ST
Practice Address - Street 2:STE 218
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-3743
Practice Address - Country:US
Practice Address - Phone:210-822-4022
Practice Address - Fax:210-930-8986
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-1058103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040551601Medicaid
VA150534OtherVALUE OPTIONS--TRICARE
MA180502OtherPHCS