Provider Demographics
NPI:1104456342
Name:BASILE, DIANA MARIE (LMT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:BASILE
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 1:29 JOHNSON CT
Mailing Address - Street 2:
Mailing Address - City:EAST NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:11732-1301
Mailing Address - Country:US
Mailing Address - Phone:516-922-7336
Mailing Address - Fax:
Practice Address - Street 1:34 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-2034
Practice Address - Country:US
Practice Address - Phone:516-755-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007004225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist