Healthcare Provider Details

I. General information

NPI: 1144356437
Provider Name (Legal Business Name): KELLY MARIE BENNETT LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 NORTH RITTER AVENUE
INDIANAPOLIS IN
46219-3027
US

IV. Provider business mailing address

6636 CROSSBRIDGE DR
NOBLESVILLE IN
46062-7361
US

V. Phone/Fax

Practice location:
  • Phone: 317-355-2560
  • Fax: 317-351-2418
Mailing address:
  • Phone: 317-773-3963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002205A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: