Provider Demographics
NPI:1851176663
Name:ALLICOCK-LIM, GAVIN SHAUN
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:SHAUN
Last Name:ALLICOCK-LIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14426 KENNEBUNK ST
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-5921
Mailing Address - Country:US
Mailing Address - Phone:858-602-9182
Mailing Address - Fax:
Practice Address - Street 1:14426 KENNEBUNK ST
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-5921
Practice Address - Country:US
Practice Address - Phone:858-602-9182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician