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1. Title -- Select One -- Dr. Mr. Mrs. Ms. Prof.
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Certification/Degree Required

First Certification or Degree Type -- Select -- N/A APRN CAC LCSW LCSW-C LGPC LGSW LICSW LISW LMFT LPC LSWA MAC Psychologist (PhD)

License #

First Certificate License Number

License State

First Certificate License State -- Select -- AFA AFC AFE AFM AK AL AP AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VI VT WA WI WV WY

Certification Date

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Expiration Date

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Certification/Degree

Second Certification or Degree Type -- Select -- N/A APRN CAC LCSW LCSW-C LGPC LGSW LICSW LISW LMFT LPC LSWA MAC Psychologist (PhD)

License #

Second Certificate License Number

License State

Second Certificate License State -- Select -- AFA AFC AFE AFM AK AL AP AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VI VT WA WI WV WY

Certification Date

Second Certification or Degree Date

Expiration Date

Second Certification or Degree Expiration Date

Certification/Degree

Third Certification or Degree Type -- Select -- N/A APRN CAC LCSW LCSW-C LGPC LGSW LICSW LISW LMFT LPC LSWA MAC Psychologist (PhD)

License #

Third Certificate License Number

License State

Third Certificate License State -- Select -- AFA AFC AFE AFM AK AL AP AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VI VT WA WI WV WY

Certification Date

Third Certification or Degree Date

Expiration Date

Third Certification or Degree Expiration Date

1.   Enter up to 3 Certificates/Degrees

1. Agency Required ... Absolute Healthcare Resources Abundant Grace Health Services Adoptions Together Affordable Behavioral Consultants All Walks of Life, LLC Amazing Love Health Services Anchor Mental Health Andromeda API Associates Aquila Recovery Center Better Mornings BHG XLVI, LLC DBA BHG Washington DC Treatment Bread for the City Calvary Healthcare, Inc Capitol Clubhouse CFSA ChAMPS CityCare Health Services Clean and Sober Streets Community Action Group Community Connections, Inc. Community Response Team Community Wellness Ventures Comprehensive Psychiatric Emergency Program (CPEP) Concerned Citizens CSOSA DBH/BHA DBH/Saint Elizabeths DC Recovery Community Alliance (DC-RCA) DCPS DDS Deaf Reach Dedicated Care Health Services DHS Doors of Hope Executive Addictive Disease Program Inc. Family & Medical Counseling Service Family Matters of Greater Washington Family Preservation Family Solutions of Ohio Family Wellness Federal City Recovery First Home Care Corporation Foundation for Contemporary Drug Abuse Global Resources & Supports Good Hope Institute Goshen Health Care and Management Services Gospel Rescue Ministry Greater Mt. Calvery Cataada House Hillcrest Children's Center Holy Comforter St. Cyprian Holy Health Care Services Humility Outreach Missionary Ministries Inner City Family Service Integrated Community Services Integrated Health Resources Jaydot Kahak Health Care Services Kinara Health and Home Care Services kolmac Clinic LaClinica Del Pueblo Latin American Youth Center Life Care Life Changing Solutions Life Enhancement Services Life Stride Mary’s Center Maryland Family Resources, Inc. MBI Health Services, LLC McClendon Center MD/DC Family Resource Mental (Behavioral) Health Services Division MPDC Neighbors Consejo New Hope Health Services, LLC New Living Health Care Services NYA Health Care Services, Inc. One Care DC Outreach Solutions P & G Behavioral Health Services Pathways to Housing DC Paving the Way Premier Behavioral Health Services, LLC Prestige Healthcare Resources Pretrial Services Agency Preventive Measures Progressive Life Project Redirect Providence Hospital PSI Psychiatric Center Chartered Psychiatric Institute of Washington Psychiatric Rehabilitation Services (PRS) DC Recovery Academy RCI-DC Counseling Center Rebound Health and Wellness Regional Addiction Prevention (RAP) Riverside Treatment Safehaven Outreach Ministry Salvation Army Samaritan Inns Inc. - Clark Inn Second Genesis So Others Might Eat Spring Leaf Solutions Mental Health Services Thrive DC Total Family Care Coalition Umbrella Therapeutic Services United Planning Organization Universal Healthcare Mngmnt Svcs Volunteers of America Chesapeake Wade & Wade Washington Hospital Center Wellness Healthcare Clinics Whitman- Walker Clinic Woodley House Youth Villages Other
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