Provider Demographics
NPI:1366041121
Name:SIMS, LATRESA RENEE
Entity type:Individual
Prefix:
First Name:LATRESA
Middle Name:RENEE
Last Name:SIMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 ARMSTRONG ST. SUITE C.
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368
Mailing Address - Country:US
Mailing Address - Phone:219-841-9166
Mailing Address - Fax:
Practice Address - Street 1:1777 ARMSTRONG ST. SUITE C.
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368
Practice Address - Country:US
Practice Address - Phone:219-841-9166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39004364A103T00000X, 103TC2200X
320900000X, 3747P1801X, 3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant