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Developmental disability / Disability / Special education / Home care / Guild for Exceptional Children / Health / Medicine / Geriatrics


Provider Enrollment Application, rev. 1, 02/28/12 Page 5 of 5 6.2
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Document Date: 2012-05-17 11:15:19


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File Size: 305,00 KB

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City

Treating Provider / /

Company

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 / official representative for your business / /

Technology

cellular telephone / /

SocialTag