Healthcare Provider Details

I. General information

NPI: 1750539417
Provider Name (Legal Business Name): SHARON A WISNIESKI OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 NORTHLAND DR SUITE 214
AUSTIN TX
78731-4945
US

IV. Provider business mailing address

12928 BLOOMFIELD HILLS LN
AUSTIN TX
78732-2066
US

V. Phone/Fax

Practice location:
  • Phone: 512-619-0303
  • Fax: 512-291-2666
Mailing address:
  • Phone: 512-291-3452
  • Fax: 512-535-6786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number109863
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: