Healthcare Provider Details

I. General information

NPI: 1164078648
Provider Name (Legal Business Name): INDIVIDUALLYTICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 E LIBERTY ST
ANN ARBOR MI
48104-2274
US

IV. Provider business mailing address

3765 SANCROFT AVE
WEST BLOOMFIELD MI
48324-2658
US

V. Phone/Fax

Practice location:
  • Phone: 248-505-3175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DENNIS NASH
Title or Position: PRESIDENT
Credential:
Phone: 248-432-0175