=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841623352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RACHEL MAE FONDREN LICSW, PIP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2013
-----------------------------------------------------
Last Update Date | 09/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 CHARGE CT APT 1F
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42701-4984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-443-0992
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 CHARGE CT APT 1F
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42701-4984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-443-0992
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 259888
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3972C
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------