Basic Information
| Provider Information | |||||||||
| NPI: | 1174658587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLECEK | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | GAIL | ||||||||
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| Credential: | MPH, OTRL | ||||||||
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| OtherLastName: | BURRIS | ||||||||
| OtherFirstName: | GINA | ||||||||
| OtherMiddleName: | GAIL | ||||||||
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| OtherCredential: | MPH, OTRL | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1161 BALSAM DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300332901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043219303 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1441 CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047120907 | ||||||||
| FaxNumber: | 4047125974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 002608 | GA | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XR0403X | 002608 | GA | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Driving and Community Mobility |
No ID Information.