Healthcare Provider Details

I. General information

NPI: 1992701882
Provider Name (Legal Business Name): NANCY M FONTENOT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 BAXTER AVE
LOUISVILLE KY
40204-2046
US

IV. Provider business mailing address

939 BAXTER AVE
LOUISVILLE KY
40204-2046
US

V. Phone/Fax

Practice location:
  • Phone: 502-456-4773
  • Fax: 502-456-9472
Mailing address:
  • Phone: 502-456-4773
  • Fax: 502-456-9472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0024
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0173
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: