Provider Demographics
NPI:1063141661
Name:INDIVIDUAL DYNAMICS
Entity type:Organization
Organization Name:INDIVIDUAL DYNAMICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-295-5559
Mailing Address - Street 1:4575 GALLEY RD STE 100D
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-2747
Mailing Address - Country:US
Mailing Address - Phone:720-295-5559
Mailing Address - Fax:
Practice Address - Street 1:4750 S SANTA FE CIR STE 5
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80110-6493
Practice Address - Country:US
Practice Address - Phone:720-468-0896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No252Y00000XAgenciesEarly Intervention Provider Agency
No385H00000XRespite Care FacilityRespite Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO19883587Medicaid