Provider Demographics
NPI:1235503962
Name:BALENTINE, LATASHA
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:BALENTINE
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 1:1100 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-1711
Mailing Address - Country:US
Mailing Address - Phone:219-885-4264
Mailing Address - Fax:
Practice Address - Street 1:1100 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1711
Practice Address - Country:US
Practice Address - Phone:219-885-4264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness