Provider Demographics
NPI:1497396287
Name:SOUTHEAST MENTAL HEALTH SERVICES
Entity Type:Organization
Organization Name:SOUTHEAST MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT AND CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-383-5448
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:719-384-5446
Mailing Address - Fax:719-384-5672
Practice Address - Street 1:437 6TH ST
Practice Address - Street 2:
Practice Address - City:LAS ANIMAS
Practice Address - State:CO
Practice Address - Zip Code:81054-1714
Practice Address - Country:US
Practice Address - Phone:719-384-5446
Practice Address - Fax:719-384-5672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-02
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13880063Medicaid