=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366041121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LATRESA RENEE SIMS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2020
-----------------------------------------------------
Last Update Date | 05/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1777 ARMSTRONG ST. SUITE C.
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-841-9166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1777 ARMSTRONG ST. SUITE C.
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-841-9166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 39004364A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 39004364A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 3747A0650X
-----------------------------------------------------
Taxonomy Name | Attendant Care Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------