Apply To Be a Provider

Name (required, Last, First, Middle)

Practice Name

Specialty

Florida License Number

Expiry Date

How long has your practice been licensed in Florida?

Have you been licensed in another state?
YesNo

If yes, list state and dates licensed (one per line)

Primary Office Address
City
State
Zip
Country
Phone No.
Fax No.

Office Manager/Contact

Email Address

Website

NPI

SSN

Office Hours

Ages Accepted

Sex
MaleFemale

Does your location provide access for the physically handicapped?
YesNo