Basic Information
| Provider Information | |||||||||
| NPI: | 1235770561 | ||||||||
| 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: | 3500 1ST ST S | ||||||||
| Address2: | |||||||||
| City: | LAMAR | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810524327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193845446 | ||||||||
| FaxNumber: | 7193845672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2019 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | ARAGON | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7193835408 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 9000153848 | 05 | CO | MEDICAID |