Healthcare Provider Details

I. General information

NPI: 1033629977
Provider Name (Legal Business Name): MARY HART BENECKE OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY HART MACLEOD

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 WISHARD BLVD
INDIANAPOLIS IN
46202-4163
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-8868
  • Fax: 317-944-6680
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number8749
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31007374A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: