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Therapist Registration Form
* Indicates required question
Therapist Type:
*
Physical Therapist
Occupational Therapist
Speech Therapist
DOB:
MM
/
DD
/
YYYY
Therapist’s Name:
*
Your answer
Address:
*
Your answer
Zip Code
*
Your answer
City, State:
*
Your answer
Phone:
*
Your answer
Fax:
Your answer
E-mail
*
Your answer
Therapist’s NPI Number:
Your answer
Therapist Medicare Number:
Please Contact office if you do not have a medicare number
Your answer
Therapist CAQH Number :
Your answer
Therapist License Number:
*
Your answer
License Effective Date
*
MM
/
DD
/
YYYY
License Expiration Date
*
MM
/
DD
/
YYYY
License Issuing State:
*
Your answer
Therapist Professional School:
Your answer
Graduation Year:
MM
/
DD
/
YYYY
Foreign Languages Spoken:
Your answer
Geographic Areas/Towns of coverage:
Your answer
Days/Hours available:
*
Your answer
Please send the following to
info@ptomni.com
or fax to: (516) 342 - 4034
Copy of License
Copy of Malpractice Insurance
W9
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