Healthcare Provider Details

I. General information

NPI: 1891345807
Provider Name (Legal Business Name): SOUTHEAST MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KENDALL DR.
LAMAR CO
81052-3901
US

IV. Provider business mailing address

711 BARNES AVE
LA JUNTA CO
81050-2138
US

V. Phone/Fax

Practice location:
  • Phone: 719-384-5446
  • Fax: 719-384-5672
Mailing address:
  • Phone: 719-384-5446
  • Fax: 719-384-5672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA CHAVEZ
Title or Position: CONTRACT & CREDENTIALING MANAGER
Credential:
Phone: 719-383-5448