Employment Provider Demographic Form Company Provider Name * Start Date * Specialty * Current Home Address * City * State * Zip * Current Mailing Address * City * State * Zip * Email Address * Phone Number * Place of Birth (City, County, State/Country) * Date of Birth * Gender Male Female Gender Neutral Alias * From which dates? * NPI Number * CAQH ID Number * **Please do not leave the username and passwords below blank. If you do not have a profile, we will initiate one for you.** NPPES Username NPPES Password CAQH Username CAQH Password: VA Medicaid Username VA Medicaid Password Board Certified? * Yes No Initial cert date Exp Date Participates in MOC? * Yes No Test taken on Sitting on DEA Number Curent Practicing -State Medical Licenses State * License # * Initial License Date * State * License # * Initial License Date * Do you have Hospital Admitting Privileges or Arrangements? Yes No Languages other than English spoken Peer References (no family members - Mid-levels, must be an MD or DO, ALL info is required Name * Street, City, State, Zip * Phone or email * Name * Street, City, State, Zip * Phone or email * CLINICAL EXPERTISE: (select all that apply indicating the top 12) ACCULTURATION ISSUES ADJUSTMENT DISORDERS ADOLESCENT BEHAVIOR DISORDERS ADOLESCENT THERAPY ADOPTION ADULT THERAPY ALCOHOL/CHEMICAL DEPENDENCY ALZHEIMER/GEROPSYC/NRSG HOME CONSULT ANESTHESIOLOGY-MRLD APPLIED BEHAVIOR ANALYST ASAM-CERTIFIED ADDICTIONOLOGIST AUTISTIC DISORDER/ASPBERGERS SYNDROME BEHAV MANAGEMENT/ALT THERAPY CHILD (FHP) BIOFEEDBACK BODY DYSMORPHIC DISORDER BORDERLINE PERSONALITY TRAITS BRIEF THERAPY BUPRENORPHINE CASE MGMT INDEPENDENT PRAC - ALL AGES CHEMICAL DEPENDENCY ASSESSMENT & REFERRAL CHILD PROTECTION/FOSTER CARE (FHP) CHILD THERAPY CHILDHOOD BEHAVIORAL DISTRUBANCES CHRISTIAN THERAPY CHRONIC PAIN CHRONIC/TERMINAL ILLNESS CNS ACUTE CNS ANESTHETISTS CNS EMERGENCY CNS GERIATRIC CNS GERONTOLOGY CNS HOLISTIC CNS HOME HEALTH CNS INFORMATICS CNS LONG TERM CARE CNS MED/SURG CNS NEONATAL CNS OCCUPATIONAL HEALTH CNS ONCOLOGY CNS PEDIATRICS CNS PERINATAL CNS PERIOPERATIVE CNS REHABILITATION CNS TRANSPLANTATION CO-OCCURRING DISORDERS COGNITIVE BEHAVIORAL THERAPY COMMUNICATION DISORDERS COMPULSIVE GAMBLING CONDUCT DISORDERS COURT ORDERED EVALUATIONS CRISIS/TRAUMA CRITICAL INCIDENT STRESS DEBRIEFING CULTURAL COMPETENCY TRAINING DEPARTMENT OF TRANSPORTATION DEVELOPMENTAL DISORDERS DEPRESSIVE DISORDERS DIAGNOSTIC ASSESSMENT LEVEL OF ASSESSMENT DIALECTICAL BEHAVIORAL THERAPY DISABILITY ASSESSMENT DISABILITY TREATMENT DISSOCIATIVE IDENTITY DISORDERS DRUG FREE WORKPLACE/FED RQMT TRAINING/CONSULT DUAL DIAGNOSIS DUAL DIAGNOSIS/DEVELOPMENTAL DISABILITIES (FHP) EATING DISORDERS ELECTROCONVULSIVE THERAPY (ECT) ELIGIBLE FOR MEDICARE REFERRALS ELIMINATION DISORDERS EMPLOYEE ASSISTANCE COUNSELING EMPLOYEE ORIENTATIONS ENHANCE EAP ACCESS BONUS ETHNIC/CULTURAL ISSUES EXPERT TESTIMONY EYE MOVEMENT DESENS. & REPROCESSING EMDR FATIH BASED THERAPY FAMILY THERAPY FAMLIY VOILENCE FTINES FOR DUTY EVALUATION FORENSICS FORENSICS/CRIMINAL JUSTCIE GAMBLNIG GANG CULTS GAY/LESBIAN/BISEXUAL/TRANSGENDER/SEXUAL GERIATRIC THERAPY GEROPSYCHIATRY/ALZHEIMERS GREIF/BEREAVEMENT GROUP THERAPY GRP THRPY ADULT GRP THRPY CHEMCIAL DEPENDENCY/SUBSTANCE ABUSE GRP THRPY CHLID GRP THRPY EATNIG DISORDERS GRP THRPY GERIATRIC GRP THRPY PANICP/HOBIA HEAD TRAUMA HEARING IMPAIRED HEARING TRAUMA HINDU THERAPY HIV/AIDS HOARDING DISORDER HOME HEALTH AGENCY SERVICES - ALL AGES HUMAN TRAFFICKING IMPULSE CONTROL DISORDER INCEST SURVIVOR INDEPENDENT EVALUATOR JEWISH EVALUATOR MAJOR DEPRESSIVE DISORDER MARITAL/SEPARATION/DIVORCE MARYLAND/MISSOURI EAP MEDICATION MANAGEMENT MENS ISSUES MENTAL HEALTH MENTAL HEALTH ISSUES MENTAL RETARDATION ISSUES MILITARY LIFESTYLE ISSUES MOTOR DISORDER/TIC DISORDER MUSLIM THERAPY NEUROPSYCHOLOGICAL TESTING NEUROPSYCHOLOGY OBSESSIVE COMPULSIVE DISORDERS ORG CHANGE MANAGEMENT/ORG DEVELOPMENT OUTPATIENT INDEPENDENT PRACTICE - ALL AGES PA & APN, APN COMMUNITY HEALTH PA &APN, APN GERONTOLOGY PANIC/PHOBIA PARAPHILIC DISORDER PARTIAL CO-OCCURING PERINATAL MENTAL HEALTH PERSONALITY DISORDERS PHYSICAL ABUSE PHYSICAL ABUSE PERPETRATOR PHYSICAL ABUSE VICTIM PHYSICALLY DISABLED PHYSICIAN ASSISTANTS ADVANCED NURSE PHYSICIAN PSYCH & NEUROMUSCULAR PHYSICIAN SERV-MRLD POST TRAUMATIC STRESS DISORDER PRACTITIONER WOMEN'S HEALTH PSYCH NEURLOGY - PSYCHOMATIC MED PSYCH NURSES LICENSED TO PRESCRIBE MEDS PSYCH TESTING IND. PRACTICE - ALL AGES PSYCHIATRIC EVALUATIONS PSYCHOANALYSIS PSYCHOLOGICAL TESTING PSYCHOPHARMACOLOGY PSYCHOSOMATIC MEDICINE PSYCHOTIC DISORDERS REACTIVE ATTACHMENT DISORDER RELAPSE/RECIDIVISM NI SUBSTANCE ABUSE RETURN TO WORK CONFERENCE SCHIZOPHRENIA SCHOOL RELATED PROBLEMS SEPARATION AND LOS (FHP) SEVERE AND PERSISTENT MENTAL ILLNESS SEXUAL ABUSE SEXUAL DYSFUNCTION SEXUAL OFFENDER TREATMENT SIGNIFICANT TRAD PROVIDER (NORTHSTAR ONLY) SLEEP DISORDERS SOCIAL DETOX SA TX ADOLESCENT SOCOM/TELEPHONIC SOMATIC/CONVERSION/FACTITIOUS DISORDERS STEP/BLENDED FAMILIES STRESS MANAGEMENT SUBOXONE THERAPY TBI BEHAVIORAL MANAGEMENT TBI COGNITIVE THERAPY TELEHEALTH SERVICES TELEPHONIC COUNSELING TELEPHONIC/ONLINE COUNSELING TOPICAL SEMINAR/BROWN BAG PRESENTATION TRANSCRANIAL MAGNETIC STIMULATION TRANSGENDER TRAUMA RESPONSE CONSULTATION TRAUMA THERAPY TRAUMATIC BRANI INJURY TREAT. OF CORRECT/LAW ENFORCEMENT OFFICIALS TREAT. OF SEXUAL PERPETRATORS TRICHOTILLOMANIA VICTIMS OF DOMESTIC VIOLENCE &CRIMES (FHP) VIDEO COUNSELING VIOLENCE IN THE WORKPLACE PREVENTION CONSULT WOMENS ISSUES WORKERS' COMPENSATION EVALUATIONS WORKPLACE ISSUES WORKSTIE DC INTERVENTION THERAPEUTIC MODALITIES: (select al that apply Indicating the top 6) BEHAVIOR MODIFICATION THERAPY BRIEF THERAPY CHILD THERAPY CHILD THERAPY <= 5 YEARS COGNITIVE BEHAVIORAL THERAPY CRTICIAL NICDIENT STRES MANAGEMENT DFWP; EAP/ORGANIZATIONAL DEVELOPMENT/WRKPL/STRESS MG DISABILITY ASSESMENT ECT INPATIENT ECT OUTPATIENT FAMLIY THERAPY GRP THRPY HOMECARE HYPNOTHERAPY MOS CHILD/FAMILY APPROVED NEUROPSYCHOLOGCIAL TESTNIG PASTORAL COUNSELING PLAY THERAPY PSYCHOLOGCIAL TESTING PSYCHOPHARMACOLOGY SOLUTION FOCUSED THERAPY VIDEO/ONLINE/TELEPHONIC Practice Information: Please indicate the percent of your curent caseload which fals niot each of the folowing categories. Client Groups: Minimum Age * Maximum Age * Client Age Range Child Age Range Percentage Adolescent Age Range Percentage Adult Age Range Percentage Geriatric/Elderly Age Range Percentage What percent of total caseload, if any, is substance abuse? Number of years at current practice Number of years clinical experience Percent of referrals from EAP Percent of referrals from Managed Care Practitioners who have indicated specialties in the following: Abuse (Physical) Forensics Child Abuse Neuropsychological Testing Eating Disorder Psychological Testing Sexual Addictions Must attest to the following criteria: Independent Licensure 10-20 hrs of documented training (cont' ed., etc) in past 1-2 years (and/or internship or post- doctoral fellowship in spclty) 200 hours of direct clinical contact in past 5 years Access to Supervision with a professional in the field AND/OR Access to Supervision with a peer supervision group Access to a prescribing provider (network or out-of-network)
