Development 3 (Adult Day Training) Supplies / Supported Living Coaching Support Coordination Limited / Personal Emergency Response Systems / Equipment Consumable Medical Supplies / Legal Representative Training (not available yet) Supplies / /
Event
Name Change / /
IndustryTerm
waiver services / insurance policies / /
Organization
Effective Date Expiration Date State Licensing Agency / Agency for Persons / New Agency / /
Person
Duty Nursing / /
Position
Mental Health Counseling Behavior Analysis Services Behavior Assistant / Behavior Assistant / Supervisor / official representative for your business / /
Provider Enrollment Application, rev. 2, 07/20/12 Page 6 of 6 2.7