Provider Demographics
NPI:1104148162
Name:BENNETT, MARY R (CMT, NCTMB)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2734 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-5314
Mailing Address - Country:US
Mailing Address - Phone:812-276-5941
Mailing Address - Fax:812-275-4654
Practice Address - Street 1:2734 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-5314
Practice Address - Country:US
Practice Address - Phone:812-276-5941
Practice Address - Fax:812-275-4654
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20900282225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist