MEDICARE: MR. TERRY B FONTENOT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	035	KY
2	106H00000X	Marriage & Family Therapist	0277	KY

General Provider Information

NPI Number	:	1689670572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TERRY B FONTENOT LCSW

Provider Business Mailing Address
First Line	:	939 BAXTER AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40204-2046
Country	:	US
Telephone Number	:	502-456-4773
Fax Number	:	502-456-9472

Provider Business Practice Location Address
First Line	:	939 BAXTER AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40204-2046
Country	:	US
Telephone Number	:	502-456-4773
Fax Number	:	502-456-9472

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	09/11/2025

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