Join our team – Mentel

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PERSONAL INFORMATION

Full name *

E-mail *

Phone number *

LICENSE INFORMATION

Enter License Number

If you selected "other", please enter the state.

LICENSE INFORMATION

What is your NPI number? *

Enter DEA Number *

If you selected "other", please enter the state.

Are you an ANCC board-certified PMHNP? *

Enter PMHNP-BC Number

Have you completed at least 3,600 hours to qualify for independent practice without a collaborative agreement? *

Do you hold any additional board certifications (FNP, AGACNP, PNP, etc.)? *

Please explain your answer

Have you ever been subject to any board actions or disciplinary proceedings by a state licensing or regulatory authority? *

Please explain your answer

LICENSE INFORMATION

Have you ever had clinical restrictions placed on your hospital, clinic, or practice privileges? *

Please explain your answer

Have you ever experienced any limitations, suspensions, or revocations of your professional license, certification, or practice authority? *

Please explain your answer

Have you ever been suspended, terminated, or asked to resign from a place of employment or clinical position? *

Please explain your answer

REWRITING THE RULES