Provider Demographics
NPI:1245462639
Name:LINE LEADER PEDIATRIC THERAPY, PLLC
Entity type:Organization
Organization Name:LINE LEADER PEDIATRIC THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:A
Authorized Official - Last Name:WISNIESKI
Authorized Official - Suffix:
Authorized Official - Credentials:MS-OTR
Authorized Official - Phone:512-619-0303
Mailing Address - Street 1:12928 BLOOMFIELD HILLS LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78732-2066
Mailing Address - Country:US
Mailing Address - Phone:512-619-0303
Mailing Address - Fax:512-291-3452
Practice Address - Street 1:3303 NORTHLAND DR
Practice Address - Street 2:SUITE 214
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4945
Practice Address - Country:US
Practice Address - Phone:512-619-0303
Practice Address - Fax:512-291-2666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109863225X00000X, 225XN1300X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitationGroup - Single Specialty