Provider Demographics
NPI:1508878331
Name:GAVIN, GEORGETTE (PHD)
Entity Type:Individual
Prefix:DR
First Name:GEORGETTE
Middle Name:
Last Name:GAVIN
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 1:2344 FIRE MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6117
Mailing Address - Country:US
Mailing Address - Phone:760-721-3637
Mailing Address - Fax:760-721-3764
Practice Address - Street 1:2344 FIRE MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6117
Practice Address - Country:US
Practice Address - Phone:760-420-1500
Practice Address - Fax:760-721-3637
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 17330103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP17330Medicare ID - Type Unspecified