Behavioral Health Provider Demographic Updates

If you are a participating provider, and would like to submit updates to your demographic information, please fill out the form below.

Please note that if you would like to add a practitioner to your Group Practice, or a Facility NPI to your organization, please fill out a Become a Provider request online instead.

Also, if you are looking to update a TIN please reach out to your Provider Relations Representative instead.

What provider type are you? Solo Practice Group Practice Facility/Agency

TIN * Please no dashes "-"

Credentialing Contact Name *

Credentialing Contact Phone *

Credentialing Contact Email *

Provider/Facility Change Form *

W-9 - required for any changes to the 1099 billing address

Supporting Document