Basic Information
| Provider Information | |||||||||
| NPI: | 1376632109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENEDICT | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 S ROGERS ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123391691 | ||||||||
| FaxNumber: | 8123788367 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 N MARR RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472016660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123143400 | ||||||||
| FaxNumber: | 8123788367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 08/27/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 35000784A | IN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000222727 | 01 | IN | ANTHEM PIN # | OTHER | 100177270A | 05 | IN | MEDICAID | 278804000 | 01 | IN | MAGELLAN PIN# | OTHER | 7075431 | 01 | IN | AETNA PIN | OTHER |