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Focus of practice:

Age Groups

Disability Groups

This information is requested for quality improvement purpose.

Licencure/Certification:

Continuing Education:

*** Please attach completed CEU/Training Log:

Specialized Training and Expertise:

Behavioral Health Level of Care Experience ( if you have 1 or more year(s) in the below levels of care, check applicable item, and years of experience).

Physicians Only: Copies of Information Must Be Attached)

Certified Nurse Practitioners Only(Please submit the Following Information)

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