Suffix State of Licensure Second State of Licensure State Association Name Are you an ACA Member? Are you an ICA Member? State or National Chapter/Conference Names Credentialing Board 1 Name Credentialing Board 1 Phone (optional) Credentialing Board 1 Address (optional) Credentialing Board 2 Name Credentialing Board 2 Phone (optional) Credentialing Board 2 Address (optional) Credentialing Board 3 Name Credentialing Board 3 Phone (optional) Credentialing Board 3 Address (optional) * Practice Name * Address1 Address2 Address3 * City/Locality State Public Practice Description
