Therapist Registration Form
Therapist Type: *
DOB:
MM
/
DD
/
YYYY
Therapist’s Name: *
Address: *
Zip Code *
City, State: *
Phone: *
Fax:
E-mail *
Therapist’s NPI Number:
Therapist Medicare Number:
Please Contact office if you do not have a medicare number
Therapist CAQH Number :
Therapist License Number: *
License Effective Date *
MM
/
DD
/
YYYY
License Expiration Date *
MM
/
DD
/
YYYY
License Issuing State: *
Therapist Professional School:
Graduation Year:
MM
/
DD
/
YYYY
Foreign Languages Spoken:
Geographic Areas/Towns of coverage:
Days/Hours available: *
Please send the following to info@ptomni.com or fax to: (516) 342 - 4034
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