* First Name *

Middle Name

* Last Name *

Suffix

* Birth Date * * *

* SSN * *

* Provider Type Acupuncturist Advance Practice Nurse Alcohol/Drug Counselor Anesthesia Assistant Applied Behavioral Analyst Athletic Trainers Audiologist Certified Registered Nurse Anesthetist Clinical Nurse Specialist Clinical Psychologist Dietitian Doctor of Chiropractic (DC) Doctor of Dental Medicine (DMD) Doctor of Dental Surgery (DDS) Doctor of Podiatric Medicine (DPM) Genetic Counselor Hospitalist Lactation Consultant – IBCLC/RLC Lactation Consultant/Educator – Certified (CLC/CLE/CLS/CBS) License Clinical Social Worker Licensed Master Social Worker Marriage/Family Therapist Medical Doctor (MD) Midwife Neuropsychologist Nurse Midwife Nurse Practitioner Nutritionist Occupational Therapist Optician Optometrist Osteopathic Doctor (DO) Pharmacist Physical Therapist Physician Assistant Professional Counselor Registered Dental Hygienist Respiratory Therapist Speech Pathologist Surgical Assistant *

* Primary Practice State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming *

* Provider NPI * * *

* License Number *

* License State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming *

DEA

UPIN

* Address *

Address 2

* City *

* State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming *

* Zip (First 5) * *

Ext Zip (Last 4) *

* Phone No * *

Phone Extension

* E-mail * *

* Confirm E-mail * *