Request for Duplicate License

A Massage and Bodywork Therapist is required by law to give written notice of name, address or employment change within 10 days of such change. Address and employment changes may be made by going to your online profile at the information update tab at Name changes must be submitted to the Board office with a photocopy of proof of your name change, i.e.: marriage license, divorce papers, or court documents relating to legal change of birth name. (A copy of your driver license or social security card is not acceptable.)
Request Information
First Name
Last Name
License #
Mailing Address
Work Phone
Cell Phone
Home Phone
Type your name as you want it to appear on your License
I am requesting: