Provider Demographics
NPI:1841623352
Name:FONDREN, RACHEL MAE (LICSW, PIP)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:MAE
Last Name:FONDREN
Suffix:
Gender:F
Credentials:LICSW, PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-2001
Mailing Address - Country:US
Mailing Address - Phone:562-443-0992
Mailing Address - Fax:
Practice Address - Street 1:1517 3RD ST NE
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-2001
Practice Address - Country:US
Practice Address - Phone:562-443-0992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3972C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL330000014Medicaid