Provider Demographics
NPI:1992701882
Name:FONTENOT, NANCY M (LCSW)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:M
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 BAXTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-2046
Mailing Address - Country:US
Mailing Address - Phone:502-456-4773
Mailing Address - Fax:502-456-9472
Practice Address - Street 1:939 BAXTER AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-2046
Practice Address - Country:US
Practice Address - Phone:502-456-4773
Practice Address - Fax:502-456-9472
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00241041C0700X
KY0173106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY82000241Medicaid
KY82000241Medicaid