Provider Demographics
NPI:1851749899
Name:RANDAZZO, DIANE (LMT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:RANDAZZO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 WEEKS ST
Mailing Address - Street 2:
Mailing Address - City:BLUE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11715-1513
Mailing Address - Country:US
Mailing Address - Phone:631-419-6300
Mailing Address - Fax:888-880-9756
Practice Address - Street 1:18 WEEKS ST
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1513
Practice Address - Country:US
Practice Address - Phone:631-419-6300
Practice Address - Fax:888-880-9756
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008337-1173C00000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist