Provider Demographics
NPI:1033629977
Name:BENECKE, MARY HART (OT)
Entity type:Individual
Prefix:
First Name:MARY HART
Middle Name:
Last Name:BENECKE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:MARY HART
Other - Middle Name:
Other - Last Name:MACLEOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 WISHARD BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4163
Practice Address - Country:US
Practice Address - Phone:317-944-8868
Practice Address - Fax:317-944-6680
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8749225XP0200X
IN31007374A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001631599OtherANTHEM PTAN
IN300058594Medicaid