Provider Demographics
NPI:1124912639
Name:FUZAILOV, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:FUZAILOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:EAST QUOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11942-3951
Mailing Address - Country:US
Mailing Address - Phone:646-288-6124
Mailing Address - Fax:
Practice Address - Street 1:429 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:EAST QUOGUE
Practice Address - State:NY
Practice Address - Zip Code:11942-3951
Practice Address - Country:US
Practice Address - Phone:646-288-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-07
Last Update Date:2025-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123234-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker