Healthcare Provider Details

I. General information

NPI: 1851749899
Provider Name (Legal Business Name): DIANE RANDAZZO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 EAST MAIN ST, SUITE SUITE 115
EAST PATCHOGUE NY
11772
US

IV. Provider business mailing address

475 EAST MAIN ST, SUITE SUITE 115
EAST PATCHOGUE NY
11772
US

V. Phone/Fax

Practice location:
  • Phone: 631-419-6300
  • Fax: 888-880-9756
Mailing address:
  • Phone: 631-419-6300
  • Fax: 888-880-9756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number008337
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number008337-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: