Update Provider Listing

Update Provider Listing 2017-04-07T23:25:05+00:00

 

SAMHIN Providers: submit this form to notify us of any changes in your provider directory listing information. We will make every effort to update your listing within one week.

If you would like to apply to be listed in our Provider Directory, please complete the Provider Registration form.

Notes: The email field is for SAMHIN use only to contact you – it will not display on your provider directory listing. Required fields are noted with a *

Your Name*

Your Email*

Organization / Company / Full Name (for private practice) - this is the main title of your current listing*

Provider Listing Changes

For the fields below, only enter any NEW or CHANGED information you would like us to update. You can view your current listing on the Provider Directory page.

MAIN LOCATION

Street Address

City

State

Zipcode

Office Phone

Office Email


SECOND LOCATION

Street Address

City

State

Zipcode

Office Phone


Website URL

Twitter URL

Facebook URL

Google+ URL

Specialties (e.g., child and adolescent psychiatry, addiction, etc.)

Degree (your degrees and / or certifications)

Treatment(s) Offered (e.g., psychotherapy, medication management, etc.)

Country of Origin

Languages

Insurance Accepted
YesNo

Medicare Accepted
YesNo

Medicaid Accepted
YesNo

Evening Hours
YesNo

Saturday Hours
YesNo

Practice Description (short paragraph about your practice or any additional affiliations such as universities)

Photo (jpg or png, maximum 1MB)

Listing Contact: for practice types Educational Institution, Mental Health Center / Clinic, or Research.

Contact First and Last Name

Contact Company

Contact Job Title and Department