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Provider Data
First Name
*
Last Name
*
Service Address (select all that apply)
*
700 N. Green Street
1740 Ridge Avenue
Work Email
*
Cell #
*
Home Phone #
Tax ID (DO NOT CHANGE)
Individual NPI #
*
Social Security Number
*
Date of Birth
*
+
CAQH # (if you don't have one, enter "none")
*
Date of State License Issue Date
*
+
Original License Issue Date (if known)
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Current License Expiration Date
*
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PTAN/Medicare # (if applicable)
Medicaid # (if applicable)
Provider Service Details
Are you accepting new clients?
*
Yes
No
Current # of clients you see
*
Preferred Client Age Range
*
Locations Handicap Accessible (DO NOT CHANGE)
Yes
No
Locations Near Transporation (DO NOT CHANGE)
Yes
No
Language Fluency (select all that apply)
*
English
Spanish
Mandarin
Cantonese
Arabic
Hebrew
Tagalog
French
Korean
Other
Other
Hours Available By Day
*
🛈
Hours
Monday
Hours
Tuesday
Hours
Wednesday
Hours
Thursday
Hours
Friday
Hours
Saturday
Hours
Sunday
Hours
Provider Specialties and Areas of Expertise
*
🛈
+
-
List of Any Memberships (NASW, etc.)
*
🛈
+
-
Provider Documents
Please scan or take a photo and upload the below, if available.
Driver's License (if available)
Title License (LCSW, etc., if available)
Resume (if available)
CAQH Info (if available)
NPI Enumeration Letter (if available)
Most Advanced Degree (if available)