Provider Demographics
NPI:1841623352
Name:FONDREN, RACHEL MAE (LICSW, PIP)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:MAE
Last Name:FONDREN
Suffix:
Gender:F
Credentials:LICSW, PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CHARGE CT APT 1F
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-4984
Mailing Address - Country:US
Mailing Address - Phone:562-443-0992
Mailing Address - Fax:
Practice Address - Street 1:105 CHARGE CT APT 1F
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-4984
Practice Address - Country:US
Practice Address - Phone:256-443-0992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2598881041C0700X
AL3972C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL330000014Medicaid