Healthcare Provider Details

I. General information

NPI: 1043789555
Provider Name (Legal Business Name): CHARLES DARRELL SLOCUM JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 N PLEASANT AVE
FRESNO CA
93728-2434
US

IV. Provider business mailing address

496 S BARTON AVE
FRESNO CA
93702-2985
US

V. Phone/Fax

Practice location:
  • Phone: 559-899-0888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW121016
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: