Psychologist-Open Enrollment

Psychologist-Open Enrollment

Practitioner Name and Credentials*

Service Location Address*

County*

Email Address*

Phone*

Are you registered with NC Tracks?*

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License Type*

License #*

NPI Number*

Are you currently credentialed with Trillium?*

(Not required, but impacts potential start date of service)

Select

Area of Expertise and Assessment Tools*

Please provide a description of your area of expertise and assessment tools used to complete Psychological Evaluations/Neuropsychological Testing.

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