Provider Demographics
NPI:1376632109
Name:BENEDICT, KELLY S (MS)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:S
Last Name:BENEDICT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-378-8367
Practice Address - Street 1:720 N MARR RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-6660
Practice Address - Country:US
Practice Address - Phone:812-314-3400
Practice Address - Fax:812-378-8367
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35000784A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000222727OtherANTHEM PIN #
IN278804000OtherMAGELLAN PIN#
IN7075431OtherAETNA PIN
IN100177270AMedicaid