All Star ABA - BCBA Credentialing Form

First, Middle and Last name*

Provider First Name

Provider Middle Name

Provider Last Name

Email Address*

List all previous Last Names*

Provider NPI*

Provider DOB*

Provider Full SSN*

Provider Current Home Address*

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Do you practice in a state that requires Licensure?*

Yes No

Do you have a VA (Virginia) license?*

Yes No

Do you have liability insurance?*

Yes No

Name of the ABA Group you will be joining?*

Actual or Anticipated Hire Date*

Select all states you'll be servicing for the ABA group.*

Please list all Insurance Companies you are enrolled for*

Provider Type*

Provider Degree*

Area of Expertise (in addition to ABA)*

List all Spoken Languages*

Provider Treating Age Range*

Your Typical Panel Size (Case Load)*

Are you a Telehealth only Provider?*

Yes No

Are you an In-Home only Provider?*

Yes No

Have you completed a Cultural Competency Training Course? If yes, what date was it completed?*

Gender

Provider Ethnicity

CAQH ID*

Email*

CAQH Username*

List all Spoken Languages*

Provider Treating Age Range*

Your Typical Panel Size (Case Load)*

Are you a Telehealth only Provider?*

Yes No

Are you an In-Home only Provider?*

Yes No

Upload Resume*

Please be sure to add All Star ABA to your resume