Healthcare Provider Details

I. General information

NPI: 1063141661
Provider Name (Legal Business Name): INDIVIDUAL DYNAMICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 S SANTA FE CIR STE 5
ENGLEWOOD CO
80110-6493
US

IV. Provider business mailing address

4575 GALLEY RD STE 100D
COLORADO SPRINGS CO
80915-2747
US

V. Phone/Fax

Practice location:
  • Phone: 720-468-0896
  • Fax:
Mailing address:
  • Phone: 720-295-5559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: KEVIN GRAVES
Title or Position: PRESIDENT/COO
Credential:
Phone: 720-295-5559