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Tell us about your other staff members
caitlin
2020-08-21T12:52:05-05:00
STEP 2
Tell us about your other staff members
Please list all the staff that work in your agency that will not be Champions.
How many staff members are in your organization?
Organization
*
Number of Staff Members
*
1
2
3
4
5
6
7
8
9
10
Contact Information: Staff Member 1
Name
*
First
Last
Position
*
Individual NPI #
(If applicable)
Individual Taxonomy #
(If applicable)
Office Phone
Mobile Phone
Email Address
*
Full Credentials
*
Primary Location
*
Program (ex. mental health outpatient)
*
Gender
Male
Female
Contact Information: Staff Member 2
Name
*
First
Last
Position
*
Individual NPI #
(If applicable)
Individual Taxonomy #
(If applicable)
Office Phone
Mobile Phone
Email Address
*
Full Credentials
*
Primary Location
*
Program (ex. mental health outpatient)
*
Gender
Male
Female
Contact Information: Staff Member 3
Name
*
First
Last
Position
*
Individual NPI #
(If applicable)
Individual Taxonomy #
(If applicable)
Office Phone
Mobile Phone
Email Address
*
Full Credentials
*
Primary Location
*
Program (ex. mental health outpatient)
*
Gender
Male
Female
Contact Information: Staff Member 4
Name
*
First
Last
Position
*
Individual NPI #
(If applicable)
Individual Taxonomy #
(If applicable)
Office Phone
Mobile Phone
Email Address
*
Full Credentials
*
Primary Location
*
Program (ex. mental health outpatient)
*
Gender
Male
Female
Contact Information: Staff Member 5
Name
*
First
Last
Position
*
Individual NPI #
(If applicable)
Individual Taxonomy #
(If applicable)
Office Phone
Mobile Phone
Email Address
*
Full Credentials
*
Primary Location
*
Program (ex. mental health outpatient)
*
Gender
Male
Female
Contact Information: Staff Member 6
Name
*
First
Last
Position
*
Individual NPI #
(If applicable)
Individual Taxonomy #
(If applicable)
Office Phone
Mobile Phone
Email Address
*
Full Credentials
*
Primary Location
*
Program (ex. mental health outpatient)
*
Gender
Male
Female
Contact Information: Staff Member 7
Name
*
First
Last
Position
*
Individual NPI #
(If applicable)
Individual Taxonomy #
(If applicable)
Office Phone
Mobile Phone
Email Address
*
Full Credentials
*
Primary Location
*
Program (ex. mental health outpatient)
*
Gender
Male
Female
Contact Information: Staff Member 8
Name
*
First
Last
Position
*
Individual NPI #
(If applicable)
Individual Taxonomy #
(If applicable)
Office Phone
Mobile Phone
Email Address
*
Full Credentials
*
Primary Location
*
Program (ex. mental health outpatient)
*
Gender
Male
Female
Contact Information: Staff Member 9
Name
*
First
Last
Position
*
Individual NPI #
(If applicable)
Individual Taxonomy #
(If applicable)
Office Phone
Mobile Phone
Email Address
*
Full Credentials
*
Primary Location
*
Program (ex. mental health outpatient)
*
Gender
Male
Female
Contact Information: Staff Member 10
Name
*
First
Last
Position
*
Individual NPI #
(If applicable)
Individual Taxonomy #
(If applicable)
Office Phone
Mobile Phone
Email Address
*
Full Credentials
*
Primary Location
*
Program (ex. mental health outpatient)
*
Gender
Male
Female
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