Provider Recruitment Opportunity: Office Based Opioid Treatment (OBOT)

Provider Recruitment Opportunity: Office Based Opioid Treatment (OBOT)

Date Submitted*

Billing Provider Name*

Provider Address, City, State, Zip Code, County*

Address will display in the Provider Directory
Address must be enrolled in NC Tracks as an active Service Location

Provider NPI*

NPI must be enrolled in NC Tracks and align with the requested service address and taxonomy

Provider Taxonomy*

Provider Tax ID*

Main Contact Name*

Main Contact Phone Number

Main Contact Email Address*

Rendering Provider Name*

Rendering Provider Credentials*

Rendering Provider NPI*

Rendering Provider Taxonomy*

Do you have a current DEA license?*

Yes

No

License #

License Expiration Date

Experience

Please detail your experience in providing care for individuals with an Opioid Use Disorder.

Send me a copy of my responses

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