Healthcare Provider Details

I. General information

NPI: 1639015274
Provider Name (Legal Business Name): DIANA CLENDANIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 VETERANS MEMORIAL HWY STE 12
COMMACK NY
11725-4300
US

IV. Provider business mailing address

93 HERBERT ST
ISLIP NY
11751-2018
US

V. Phone/Fax

Practice location:
  • Phone: 631-319-7678
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP139641
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: