Healthcare Provider Details

I. General information

NPI: 1730956293
Provider Name (Legal Business Name): RECOVER UNDERCOVER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 CALEBS PATH EXT STE 122
HAUPPAUGE NY
11788-5224
US

IV. Provider business mailing address

1600 CALEBS PATH EXT STE 122
HAUPPAUGE NY
11788-5224
US

V. Phone/Fax

Practice location:
  • Phone: 631-994-1075
  • Fax: 631-350-0293
Mailing address:
  • Phone: 631-994-1075
  • Fax: 631-350-0293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. CATHY RANDOLPH
Title or Position: OWNER
Credential: NP
Phone: 631-546-8849