Facility Name

 Address

Ph #  
Fax #
E-mail 

SPECIALTY PROGRAMS - (Eating Disorder Program, Closed Door Facility, Sexual Dysfunction Treatment, etc.)
 
 

DIAGNOSES TREATED - (list primary diagnoses treated, especially unusual diagnoses.)

 

CONTACT PERSON FOR ADMISSIONS
Name             ph #
E-mail  

CONTACT PERSON FOR CONTRACTING
Name             ph #
E-mail  

Web Site Address  

Other information you would like to include in your listing

 

Sections in which listing is to appear:
(Check all that apply)

 
Optional - Please specify other states in which listing is to appear (i.e.: neighboring states).

Check box if your facility is a Tricare Designated Preferred Provider