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Type Code 2. Licensee Name 4. Professional License Number 3. National Provider Identifier NPI 5. Social Security Number 6. Date of Birth 7. Primary Service Address City State Primary Address Phone Number Fax Number Email 8. Mailing Address Zip Code 9. Drug Enforcement Agency DEA Number. If the provider does not have a DEA Number enter N/A. 10. Has there ever been disciplinary action against this provider s license by a licensing board in any state Yes No IF YES PLEASE ATTACH AN EXPLANATION 11. ...

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