Application Form / Data Collection | Private Practice Net

Company Name

Group NPI

Tax ID #

Primary Location Address

Authorized Official's Full Name

Authorized Official's Email

Authorized Official's Cellphone

Years in business

Number of Providers across all locations

Number of Practice Locations

Services Offered

In-Office Therapy

Virtual Therapy

In-Home Therapy

Extended hours are available (before 9am and after 6pm)

Weekend hours available

Time to Appointment

How fast can you get new patients in?

CPT Codes: Most frequently ordered