Healthcare Provider Details

I. General information

NPI: 1477096725
Provider Name (Legal Business Name): STACY LOVELL SLOCUM I APCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2016
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 N VAN NESS AVE
FRESNO CA
93728-3429
US

IV. Provider business mailing address

2733 E ROCKINGHAM CT
FRESNO CA
93720-5340
US

V. Phone/Fax

Practice location:
  • Phone: 559-268-7613
  • Fax:
Mailing address:
  • Phone: 559-573-4863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT 34689
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: