Provider Demographics
NPI:1073118394
Name:SOUTHEAST MENTAL HEALTH SERVICES
Entity Type:Organization
Organization Name:SOUTHEAST MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ARAGON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-383-5408
Mailing Address - Street 1:711 BARNES AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-2138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 E 1ST ST
Practice Address - Street 2:
Practice Address - City:ORDWAY
Practice Address - State:CO
Practice Address - Zip Code:81063-1433
Practice Address - Country:US
Practice Address - Phone:719-384-5446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08880051Medicaid