Basic Information
| Provider Information | |||||||||
| NPI: | 1184265985 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST MENTAL HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 BARNES AVE | ||||||||
| Address2: | |||||||||
| City: | LA JUNTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810502138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193845446 | ||||||||
| FaxNumber: | 7193845672 | ||||||||
| Practice Location | |||||||||
| Address1: | 14833 S RITTGERS ST | ||||||||
| Address2: | |||||||||
| City: | EADS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810369514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193845446 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2019 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | CHAVEZ | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACT AND CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7193835448 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 15880052 | 05 | CO | MEDICAID |