Provider Demographics
NPI:1104343359
Name:HECIMOVIC, DAMIR (OTR/L)
Entity type:Individual
Prefix:
First Name:DAMIR
Middle Name:
Last Name:HECIMOVIC
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 OAK ALLEY CT
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8032
Mailing Address - Country:US
Mailing Address - Phone:678-576-7563
Mailing Address - Fax:
Practice Address - Street 1:7 DUNWOODY PARK STE 104
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6711
Practice Address - Country:US
Practice Address - Phone:678-576-7563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2021-04-06
Deactivation Date:2021-01-20
Deactivation Code:
Reactivation Date:2021-02-03
Provider Licenses
StateLicense IDTaxonomies
GAOT006446225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT006446Medicaid