Applicant Information First Middle Last Email Address Valid email is required Date of Birth Gender Female Male Social Security Number NPI Type 1 CAQH ID Primary Degree Type Example: Masters of Psychology| Doctor of Psychology Professional Licence or Certification Example: LPC- Licensed Professional Counselor Supervising Physician (If under supervision) Mailing Address Street/ PO Box Mailing Address Suite Mailing Address Zip Code From W-9 Taxpayer Information Filed with the IRS Do you use your Social Security number? Do you use a TIN? Business Name Tax Identification Number Tax Payer Street Address Tax Payer Street Address #2 Tax Payer Zip Code Pay to Information: Business Name Pay to Information: NPI Type 2 Primary Service Location: Location Street Primary Service Location: Location Suite Primary Service Location: Location Zip Code Is office in your home? Yes No Service Location Phone Service Location Fax Service Location Crisis Phone Other Languages you speak Specialty Networks- Disorder and treatment modalities? Patient Populations: Please select at least one Child (ages 1-5) Child (ages 6-10) Adolescent (ages 13-17) Adult (ages 18+) Geriatric (ages 65+) Do you provide qualified telehealth services? No- I do not provide qualified behavioral telehealth services Yes- I attest that I provide qualified behavioral telehealth services Employee Assistant Program (EAP) Specialty Services- EAP assessment and referral services EAP assessment and referral services Critical Incident Response (CIR) service Provide general EAP Management referrals Substance Abuse Expert Employee Assistance Professional (CEAP) Employee educational seminars Substance abuse professional (SAP) cert EAP Supervisory Training Sessions Share this:TweetShare on TumblrPocketPrintWhatsAppMoreReddit
