Healthcare Provider Details

I. General information

NPI: 1801930425
Provider Name (Legal Business Name): CYNTHIA L FONDREN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 DESTINY LN STE 104
BOWLING GREEN KY
42104
US

IV. Provider business mailing address

1830 DESTINY LN STE 104
BOWLING GREEN KY
42104-1088
US

V. Phone/Fax

Practice location:
  • Phone: 270-901-5000
  • Fax:
Mailing address:
  • Phone: 513-341-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number241316
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: