Request for Verification of North Carolina Licensure
Therapist Information
First Name
required
Last Name
required
License #
required
Mailing Address
required
City
required
State
required
Zip
required
Work Phone
please enter at least one phone number
Cell Phone
Home Phone
Email
required
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Please send verification of my North Carolina licensure to the following state agency or company.
Company/State Agency
Company/State agency name
required
Mailing Address
required
City
required
State
required
Zip
required
Email (optional)
invalid email
Contact Person (optional)
Send Verification To:
Company/State Agency
Therapist