Name/Address Change of Provider 620-01-75-01

(Revised 4/3/23 ML #3717)

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1. The current provider who is requesting a name change must complete a new application and submit documentation verifying the name change.

    

2. A current provider who is relocating to a new address must complete a new application, and a new licensing study or self-declaration will be completed. A new license number will be issued upon license approval.

    

3. Fees and fee adjustments during a licensing, self-declaration, or registration period falls under the discretion of the Licensing Specialist.