Home » Change Your Contact Information

Change Your Contact Information

Type of License or Application:* *

PT
PTA
OT
OTA

Are you supervising someone with a Temporary License?: *

Yes
No

LICENSE # / Applicant Password:

EXPIRATION DATE:

Name *

First

Last

Email *

New Business Address

Business addresses are public information.

Employer Name:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Enter phone numbers with spaces - 512 754 1245

Phone

New Home Location Information

Address

Address Line 1

Address Line 2

City

State

Zip Code

Enter phone numbers with spaces - 512 754 1245

Phone

New Mailing Address

Address

Address Line 1

Address Line 2

City

State

Zip Code