Practitioner Details
Initial Provider Credentialing Request - Personal Information
Instructions:
Complete the section below and the address section on the following screen. Once you begin your request, you must complete it in one session as you will not be able to save it and complete at a later time. Once you submit an Initial Provider Credentialing Request, you will not be able to change and re-submit. Fill in all applicable fields and review your data for accuracy. After completing this section, click Next to enter address information.
Name
Last Name
First Name
Middle
Suffix
II
III
IV
Jr
Sr
V
VI
National Provider ID
(individual, not group)
Date of Birth
mm/dd/yyyy
CAQH ID
Highmark ID
(individual, not group)
Practitioner Type
ACUPUNCTURIST
AUDIOLOGIST
BEHAVIORAL SPECIALIST
CERTIFIED ADDICTION COUNSELOR (CAC) (MG)
CHIROPRACTOR
DENTAL HYGIENIST
DENTIST
LICENSED MASSAGE THERAPIST
LICENSED PROFESSIONAL COUNSELOR
MARRIAGE AND FAMILY THERAPISTS
MEDICAL DOCTOR
MIDWIFE, CERTIFIED
NATUROPATH
NURSING
NUTRITIONIST-DIETICIAN
OCCUPATIONAL THERAPIST
OPTOMETRIST
OSTEOPATHIC DOCTOR
PARAMEDIC
PASTORAL COUNSELOR
PHARMACIST
PHYSICAL THERAPIST
PHYSICIAN ASSISTANT
PODIATRIST
PSYCHOLOGIST
RESPIRATORY THERAPIST
SOCIAL WORKER
SPEECH & LANGUAGE PATHOLOGIST
TEACHER OF THE HEARING IMPAIRED
Degree
Academy of Cert Soc Workers
Advanced Practice Registered Nurse
Alcohol and Other Drug Abuse
Audiologist
Bach of Science IN Hlth Studies
Bach of Science In Nursing
Bach of Science and Social Work
Bachelor of Arts
Bachelor of Med & Bachelor of Surg
Bachelor of Medical
Bachelor of Science
Board Certified Behavior Analyst
CRN Anesthetist
CRN Practitioner
Cert Alcohol and Drug Abuse Counselor
Cert Chemical Dependency Counselor
Cert Fellow Am Coll of Hlthcare Exec
Cert In Prof Health Care Quality
Certificate of Advanced Study
Certified Addiction Counselor
Certified Alcohol and Drug Counselor
Certified Ambulatory Post Anesthesia
Certified Diabetic Educator
Certified First Assistant
Certified Gastroenterology
Certified Genetic Counselor
Certified Health Consultant
Certified Independent Social Worker
Certified Massage Therapist
Certified Medical Assistant
Certified Mental Health Admin
Certified Mental Health Worker
Certified Nurse Practitioner
Certified Nursing Assistant
Certified Nursing Home Admin
Certified Operating Room Nurse
Certified Ophthalmic Assistant
Certified Ophthalmic Medical Tech
Certified Ophthalmic Technician
Certified Social Worker
Certified Social Worker - PIP
Certified Substance Abuse Counselor
Chemical Dependency Counselor
Chiropractor
Clinical Laboratory Director
Clinical Nurse Specialist
Clinical Spec Psych/Mental Health
College of American Pathologists
Community Health Worker
Dental Hygienist
Doctor of Dental Medicine
Doctor of Dental Surgery
Doctor of Education
Doctor of Marriage and Family
Doctor of Medical Science
Doctor of Ministry
Doctor of Nursing Practice
Doctor of Nursing Science
Doctor of Optometry
Doctor of Osteopathy
Doctor of Pharmacy
Doctor of Podiatry Medicine
Doctor of Professional Counsel
Doctor of Psychology
Doctor of Public Health
Doctor of Social Welfare
Education Specialist
Employee Assistant Program
Family Nurse Practitioner
Family Nurse Practitioner
Family Nurse Practitioner
Family Nurse Practitioner
Fellow of Am Ac of Nursing
Fellow of Am Coll of Add Trmnt Admin
Fellow of Am Coll of Hlthcare Exec
Fellow of Am Coll of Med Grp Admin
Fellow of Am Coll of Physicians
Fellow of Am Coll of Surgeons
Fellow of Royal Coll of Phys and Surg of Canada
Foreign Medical Degree
Health System Administrator
Licensed Acupuncturist
Licensed Addiction Counselor
Licensed Addiction Therapist
Licensed Alcohol and Drug Counselor
Licensed Associate Marriage and Family Therapist
Licensed Baccalaureate Social Worker
Licensed Certified Social Worker
Licensed Clinical Social Worker
Licensed Dietician
Licensed Graduate Social Worker
Licensed Independent Clinical Social Worker
Licensed Independent Social Worker
Licensed Independent Social Worker
Licensed Independent Social Worker
Licensed Independent Social Worker
Licensed Marriage Family Therapist
Licensed Massage Therapist
Licensed Master Ofhealth Care
Licensed Master Social Worker
Licensed Master of Social Work
Licensed Mental Health Counselor
Licensed Mental Health Counselor
Licensed Mental Health Counselor
Licensed Mental Health Counselor
Licensed Nursing Home Admin
Licensed Nutritionist
Licensed Optician
Licensed Practical Nurse
Licensed Prof Clinical Counselor
Licensed Professional Counselor
Licensed Professional Counselor-Mental Health
Licensed Psychological Practitioner
Licensed Psychologist
Licensed Registered Dietician
Licensed Social Worker
Licensed Traditional Midwife
Limited Licensed Practitioner
Limited Licensed Psychologist
Marriage and Family Therapist
Marriage/Family/Child Counselor
Massage Therapist
Master of Arts
Master of Behavioral Science
Master of Clinical Psychology
Master of Counseling
Master of Divinity
Master of Education
Master of Professional Studies
Master of Public Health
Master of Rehabilitation Counsel
Master of Science
Master of Science Hlth Service Admin
Master of Science In Nursing
Master of Science In Public Health
Master of Science In Social Work
Master of Theological Studies
Masters Equivalent
Masters IN Hlth Sciences, Master IN Human Service
Medical Doctor
Mental Health Association
Midwife, Certified
Midwife, Certified Registered
National Perinatal Association
Natl Cert of Alcohol Abd Drug Counselors
Nursing Home Administrator
Occupational Therapist
Oncology Certified Nurse
Operating Room Supervisor
Oriental Medical Doctor
Other Masters Prepared Therapist
Personal Care Attendant
Physical Therapist
Physicians Assistant
Podiatrist
Professional Counselor
Psychiatric Nurse
Psychologist
Registered Applied Behavior Analyst
Registered Dietician
Registered Lactation Consultant
Registered Nurse
Registered Nurse Clinical Nurse Specialist
Registered Nurse First Assistant
Registered Nurse Practitioner
Registered Pharmacist
Registered Physical Therapist
Respiratory Therapist
Senior Certified Addiction Counselor
Social Work Associate
Social Worker
Speech Language Pathologist
Surgical Nursing Assistant
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X-Ray Tech
Please only provide the specialties and roles for which you are requesting Credentialing. This information will be used in our Network Directory.
Primary Specialty
Primary Specialty Role
Secondary Specialty
Secondary Specialty Role
Credentialing Contact Email Address
Credentialing Contact Name