Licensed Associate Interest Form

Holland and Associates Counseling, PLLC

First name

Last name

Email address

Phone number

License Number

Please provide approximate or anticipatory date if unlicensed.

National Provider Identification (NPI)

CAQH Provider ID

Files - Please upload in PDF formatting: Professional Disclosure Statement, Resume, CAQH Profile and Example Documentation You can add multiple files

Add file

Please upload a file

Your information will be encrypted.