Provider Demographics
NPI:1457595373
Name:FUZAYLOV, VIOLLETA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:VIOLLETA
Middle Name:
Last Name:FUZAYLOV
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:VIOLLETA
Other - Middle Name:
Other - Last Name:FUZAYLOV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:6511 BOOTH ST
Mailing Address - Street 2:SUITE 1 C
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4181
Mailing Address - Country:US
Mailing Address - Phone:347-738-1197
Mailing Address - Fax:
Practice Address - Street 1:6511 BOOTH ST
Practice Address - Street 2:SUITE 1 C
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4181
Practice Address - Country:US
Practice Address - Phone:347-738-1197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-22
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019822235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist