Provider Info Form Dear New CHCRR Provider, To streamline gathering information, please take a moment to fill out the form below so that we can list you on the CHCRR.org website. We would appreciate as much information as possible. "*" indicates required fields Name* First Middle Last Suffix HiddenPost Title Phone Email Specialty & InterestsSpecialty* Adolescent Medicine Adolescent Psychiatry Alcohol and Drug Counselor Behavioral Health Child Psychiatry Child Psychology Clinical Social Work Dance/Movement Therapist Dental Medicine Dentist Dentist/Pediatric Diabetes and Obesity Prevention Diabetes Management Express Care Family Medicine Hygienist Infectious Diseases Internal Medicine LBGTQIA+ Medication Assisted Treatment (MAT) Mental Health Counselor Migrant & Refugee Social Work Opioid Addiction Pediatric Dental Hygienist Pediatrics Pharmacy Psychiatry Professional InterestsList topics, separated with a commaAdditional Professional InformationFree form paragraph about special professional interests.Philosophy of CareFree form paragraphsPersonal Info/interests (family, hobbies, interesting background)Personal Information to share publiclyEducation, Training & CertificationsI am a:*Select all that apply. Medical Doctor Nurse Nurse Practioner Physician Assistant Psychiatrist Certified Educator Certified/Registered Therapist/Clinician Counselor Social Worker Pharmacist Medical Doctor Title AuD - Doctor of Audiology DC - Doctor of Chiropractic DDS - Doctor of Dental Surgery, Doctor of Dental Science DMD - Doctor of Dental Medicine, Doctor of Medical Dentistry DO - Doctor of Osteopathic Medicine DO - Doctor of Ophthalmology DPM - Doctor of Podiatric Medicine DPT - Doctor of Physical Therapy DScPT - Doctor of Science in Physical Therapy DSN - Doctor of Science in Nursing ENT - Ear, nose and throat specialist GP - General Practitioner GYN - Gynecologist MD - Doctor of Medicine MS - Master of Surgery OB/GYN - Obstetrician and Gynecologist PharmD - Doctor of Pharmacy Psychiatrist Title PsyD - Doctor of Psychology Nurse Title RNC – Certified Registered Nurse RNFA – Registered Nurse First Assistant RN – Registered Nurse PHN – Public Health Nurse APRN – Advanced Practice Registered Nurse CCRN – Critical Care Registered Nurse CNM – Certified Nurse Midwife CNS – Clinical Nurse Specialist Nurse Practitioner Title ANP – Adult Nurse Practitioner FNP – Family Nurse Practitioner FNP-C – Certified Family Nurse Practitioner NP – Nurse Practitioner NP-C – Certified Nurse Practitioner PNP – Pediatric Nurse Practitioner PMHNP-BC - Psychiatric-mental health nurse practitioner Board Certified WHNP – Women's Health Nurse Practitioner CFNP – Certified Family Nurse Practitioner Physician Assistant Title MPAS - Master of Physician Assistant Studies PA – Physician Assistant PA-C – Certified Physician Assistant Certified Educator Title AE-C – Certified Asthma Educator BC-ADM – Board Certified, American Diabetic Association CDE – Certified Diabetes Educator CLE – Certified Lactation Educator Certified/Registered Therapist/Clinician Title AU – Audiologist CCC-A – Certificate of Clinical Competence in Audiology CCC-SLP – Certificate of Clinical Competence in Speech-Language Pathology CDTC – Certified Diabetes Technology Clinician CHT – Certified Hand Therapist CNSC – Certified Nutrition Support Clinician CNSD – Certified Nutrition Support Dietitian COMT – Certified Ophthalmic Medical Technologist CPM – Certified Professional Midwife CSCS – Certified Strength and Conditioning Specialist CSO – Certified Specialist in Oncology Nutrition CSSD – Certified Specialist in Sports Dietetics IBCLC – International Board Certified Lactation Consultant PT – Physical Therapist RD – Registered Dietitian RCP – Respiratory Care Practitioner SCS – Certified Sports Specialist RDH - Registered Dental Hygienist RPh - Pharmacist Counselor Title CADC - Certified Alcohol and Drug Abuse Counselor CGC – Certified Genetic Counselor LADC - Licensed Alcohol Drug Abuse Counselor Social Worker Title LICSW - Licensed Independent Clinical Social Worker LCSW – Licensed Clinical Social Worker Medical Education*Name of School Year of Graduation/Certification Internship LocationName of hospital/school Residency LocationName of hospital/school License StateCheck all that apply VT NH NY MA CT Other Other StatesPlease list using abbreviations Board CertificationsList of Certifications, separated with a commaFellowshipsList of Fellowships, separated with a commaMembershipsList of Professional Memberships, separated with a commaCommunity Health Location(s) where you practice* Community Health Allen Pond Community Health Brandon Community Health Castleton Community Health Mettowee Community Health North Main Community Health Pediatrics Community Health Rutland Community Health Shorewell Express Care Castleton Express Care Rutland Community Dental Rutland Community Dental Shorewell Community Kids Dental HiddenLocationsCheck each location where you practice Mettowee Valley Brandon Medical Center Allen Pond Health Center Castleton Family Health Center Rutland Community Health Center Rutland Behavioral Health Center CHCRR Community Dental CHCRR Pediatrics Shorewell Community Health Center Anything we missed that you'd like to add?Below, please include any additional information you'd like to include that such as a designation, title, etc. PhoneThis field is for validation purposes and should be left unchanged.
