Provider Demographics
NPI:1386408649
Name:KHUKHASHVILI, DIANA (LMSW)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:
Last Name:KHUKHASHVILI
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 MONTEBELLO RD
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-3746
Mailing Address - Country:US
Mailing Address - Phone:845-523-9500
Mailing Address - Fax:
Practice Address - Street 1:3 DONALD AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-1912
Practice Address - Country:US
Practice Address - Phone:347-232-2390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115410104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker