Request for Verification of North Carolina Licensure

Therapist Information
First Name
Last Name
License #
Mailing Address
City
State
Zip
Work Phone
Cell Phone
Home Phone
Email

Please send verification of my North Carolina licensure to the following state agency or company.

Company/State Agency
Company/State agency name
Mailing Address
City
State
Zip
Phone # (optional)
Contact Person (optional)
Send Verification To: