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1. Professional & Licensure Information
What is your profession?*
Counselor
Psychiatrist
Psychologist
Social worker
Degree*
EdD
LCSW
LMFT
MA
MD
MFT
MS
MSW
PhD
PsyD
What service(s) do you provide?*
Individual therapy
Couples therapy
Group therapy
Psychopharmacological treatment
Educational testing
Cognitive testing
Other - please specify
Primary License State*
Select a State...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Primary License Number*
Additional Licenses
Please add state (or abbreviation)Â and license number
Add license
Which modes of therapy do you provide? *
Virtual only
Virtual and in-person
In-person only
Do you have an interjurisdictional compact that allows you to practice teletherapy across state lines? *
No
Yes
What is your NPI (National Provider Identification) number?
What is your EIN (Employer Identification Number)?*
If you have not set up an independent business, this would be your social security number (SSN)
Be sure to save your changes before moving on!
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