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Username
Only lowercase letters allowed (Capital letters not allowed)
Password
Email address
Primary Email Address Type
Personal
Business
First name
Last name
Preferred Pronouns
Department
Country
AF|Afghanistan
AX|Åland Islands
AL|Albania
DZ|Algeria
AS|American Samoa
AD|Andorra
AO|Angola
AI|Anguilla
AQ|Antarctica
AG|Antigua and Barbuda
AR|Argentina
AM|Armenia
AW|Aruba
AU|Australia
AT|Austria
AZ|Azerbaijan
BS|Bahamas
BH|Bahrain
BD|Bangladesh
BB|Barbados
BY|Belarus
BE|Belgium
BZ|Belize
BJ|Benin
BM|Bermuda
BT|Bhutan
BO|Bolivia (Plurinational State of)
BQ|Bonaire, Sint Eustatius and Saba
BA|Bosnia and Herzegovina
BW|Botswana
BV|Bouvet Island
BR|Brazil
IO|British Indian Ocean Territory
BN|Brunei Darussalam
BG|Bulgaria
BF|Burkina Faso
BI|Burundi
CV|Cabo Verde
KH|Cambodia
CM|Cameroon
CA|Canada
KY|Cayman Islands
CF|Central African Republic
TD|Chad
CL|Chile
CN|China
CX|Christmas Island
CC|Cocos (Keeling) Islands
CO|Colombia
KM|Comoros
CG|Congo
CD|Congo (the Democratic Republic of the)
CK|Cook Islands
CR|Costa Rica
CI|Côte d'Ivoire
HR|Croatia
CU|Cuba
CW|Curaçao
CY|Cyprus
CZ|Czechia
DK|Denmark
DJ|Djibouti
DM|Dominica
DO|Dominican Republic
EC|Ecuador
EG|Egypt
SV|El Salvador
GQ|Equatorial Guinea
ER|Eritrea
EE|Estonia
SZ|Eswatini
ET|Ethiopia
FK|Falkland Islands (Malvinas)
FO|Faroe Islands
FJ|Fiji
FI|Finland
FR|France
GF|French Guiana
PF|French Polynesia
TF|French Southern Territories
GA|Gabon
GM|Gambia
GE|Georgia
DE|Germany
GH|Ghana
GI|Gibraltar
GR|Greece
GL|Greenland
GD|Grenada
GP|Guadeloupe
GU|Guam
GT|Guatemala
GG|Guernsey
GN|Guinea
GW|Guinea-Bissau
GY|Guyana
HT|Haiti
HM|Heard Island and McDonald Islands
VA|Holy See
HN|Honduras
HK|Hong Kong
HU|Hungary
IS|Iceland
IN|India
ID|Indonesia
IR|Iran (Islamic Republic of)
IQ|Iraq
IE|Ireland
IM|Isle of Man
IL|Israel
IT|Italy
JM|Jamaica
JP|Japan
JE|Jersey
JO|Jordan
KZ|Kazakhstan
KE|Kenya
KI|Kiribati
KP|Korea (the Democratic People's Republic of)
KR|Korea (the Republic of)
KW|Kuwait
KG|Kyrgyzstan
LA|Lao People's Democratic Republic
LV|Latvia
LB|Lebanon
LS|Lesotho
LR|Liberia
LY|Libya
LI|Liechtenstein
LT|Lithuania
LU|Luxembourg
MO|Macao
MG|Madagascar
MW|Malawi
MY|Malaysia
MV|Maldives
ML|Mali
MT|Malta
MH|Marshall Islands
MQ|Martinique
MR|Mauritania
MU|Mauritius
YT|Mayotte
MX|Mexico
FM|Micronesia (Federated States of)
MD|Moldova (the Republic of)
MC|Monaco
MN|Mongolia
ME|Montenegro
MS|Montserrat
MA|Morocco
MZ|Mozambique
MM|Myanmar
NA|Namibia
NR|Nauru
NP|Nepal
NL|Netherlands
NC|New Caledonia
NZ|New Zealand
NI|Nicaragua
NE|Niger
NG|Nigeria
NU|Niue
NF|Norfolk Island
MK|North Macedonia
MP|Northern Mariana Islands
NO|Norway
OM|Oman
PK|Pakistan
PW|Palau
PS|Palestine, State of
PA|Panama
PG|Papua New Guinea
PY|Paraguay
PE|Peru
PH|Philippines
PN|Pitcairn
PL|Poland
PT|Portugal
PR|Puerto Rico
QA|Qatar
RE|Réunion
RO|Romania
RU|Russian Federation
RW|Rwanda
BL|Saint Barthélemy
SH|Saint Helena, Ascension and Tristan da Cunha
KN|Saint Kitts and Nevis
LC|Saint Lucia
MF|Saint Martin (French part)
PM|Saint Pierre and Miquelon
VC|Saint Vincent and the Grenadines
WS|Samoa
SM|San Marino
ST|Sao Tome and Principe
SA|Saudi Arabia
SN|Senegal
RS|Serbia
SC|Seychelles
SL|Sierra Leone
SG|Singapore
SX|Sint Maarten (Dutch part)
SK|Slovakia
SI|Slovenia
SB|Solomon Islands
SO|Somalia
ZA|South Africa
GS|South Georgia and the South Sandwich Islands
SS|South Sudan
ES|Spain
LK|Sri Lanka
SD|Sudan
SR|Suriname
SJ|Svalbard and Jan Mayen
SE|Sweden
CH|Switzerland
SY|Syrian Arab Republic
TW|Taiwan
TJ|Tajikistan
TZ|Tanzania, the United Republic of
TH|Thailand
TL|Timor-Leste
TG|Togo
TK|Tokelau
TO|Tonga
TT|Trinidad and Tobago
TN|Tunisia
TR|Turkey
TM|Turkmenistan
TC|Turks and Caicos Islands
TV|Tuvalu
UG|Uganda
UA|Ukraine
AE|United Arab Emirates
GB|United Kingdom
US|United States
UM|United States Minor Outlying Islands
UY|Uruguay
UZ|Uzbekistan
VU|Vanuatu
VE|Venezuela (Bolivarian Republic of)
VN|Viet Nam
VG|Virgin Islands (British)
VI|Virgin Islands (U.S.)
WF|Wallis and Futuna
EH|Western Sahara
YE|Yemen
ZM|Zambia
ZW|Zimbabwe
Principal Employment/Practice Setting
Choose...
Academic Health Center
Administrative Facility
Advocacy Organization
AIDS Service Organization (ASO)
Capacity Building Partner
College/University
Community-Based/Retail Pharmacy
Community-Based Organization (CBO)
Correctional Facility/Institution
Faith-Based Organization (FBO)
Health Center (e.g., Federally Qualified Health Center, FQHC Look-Alike)
Health Clinic
Health Services Facility
Health Maintenance Organization/Managed Care Organization
Hospital/Hospital-Affiliated Clinic
Indian Health Services
Local Health Department
Military Health System/Veteran’s Health
Non-Profit Organization
Pharmaceutical Manufacturer
Private Practice (Solo/Group)
Rural Health Center
Social Service Organization
State Health Department
Third-Party Payor
Not Affiliated with an Organization
Other
Principal Employment/Practice Setting - Other
Job Title
Degree(s)
Primary Function/Profession
Choose...
Administrator
Advocate
Case Management
Clergy/Faith-based Professional
Community Health Worker
Dentist
Dietician/Nutritionist
Disease Intervention Specialist
Finance/Fiscal Manager
Harm Reductionist/Risk Reductionist
Health Education Specialist
Health Navigator
Licensed Practical Nurse
Medical Assistant
Medical billing
Mental Health Case Manager
Mental Health Professional
Nurse Practitioner
Nursing Case Manager
Occupational therapist
Outreach Worker
Patient/Consumer
Pharmacist
Pharmacy Technician
Psychologist
Physician Assistant
Physician
Registered Nurse
Researcher
Social Worker
Student
Substance Abuse Counselor/ Professional
Other Provider/Professional
Primary Function/Profession - Other
Primary Area of Specialization/Focus
Choose...
Addiction Medicine
Allergy and clinical immunology
Cardiology
Critical care/ intensive care
Dentistry
Dermatology
Diabetes
Emergency medicine
Endocrinology
Family medicine
Gastroenterology
General practice
Geriatrics
Hematology
Hepatology
HIV/AIDS
Hospice/palliative care
Infectious Diseases
Internal Medicine
Neonatal/Perinatal Medicine
Nephrology
Neurology
Neurosurgery
Nutrition
OB/GYN and Women’s Health
Oncology
Ophthalmology
Otolaryngology
Pain Management
Pathology
Pediatrics
Preventative medicine
Psychiatry
Psychology
public/community health
Pulmonary medicine
Radiology
Rheumatology
Sleep medicine
Sports Medicine
Surgery
Transplantation
Urology
Vascular medicine
Other
Primary Area of Specialization/Focus - Other
Continued Education Credits
Yes
No
Continuing Education Credit Type
American Medical Association (MDs, DOs)
American Medical Association (NPs, PAs)
American Academy of Physician Assistants (PAs)
Accreditation Council for Pharmacy Education (Pharmacists)
American Nurses Credentialing Center (Registered Nurses)
American Psychological Association (Psychologists)
Association of Social Work Boards (ASWB)
Certificated Health Education Specialists Credits/Master Certified Health Education Specialist (CHES/MCHES)
Certified Public Health Recertification (CPH)
None
ABIM#
CHES/MCHES#
NABP#
NBPHE#
NPI#
RLN#
Other License Number
Birth Month
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01
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Birth Day
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Initial License Year
Choose...
1930
1931
1932
1933
1934
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1936
1937
1938
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2012
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2014
2015
2016
2017
2018
2019
2020
2021
City/town
Business Phone..
Business Address 1
Business Address 2
Business City
Business State, Province or Territory.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
United States Minor Outlying Islands
Virgin Islands, U.S.
State(s) Licensed
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
United States Minor Outlying Islands
Virgin Islands, U.S.
DC Ward
Ward 1
Ward 2
Ward 3
Ward 4
Ward 5
Ward 6
Ward 7
Ward 8
Birth Year
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
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2015
2016
2017
2018
2019
2020
2021
Gender Identity
Choose...
Agender
Androgyne
Demigender
Genderqueer/ Gender fluid
Man
Questioning/Unsure
Trans man
Trans woman
Woman
Other
Racial Background
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other
Origin
Yes
No
Spoken Languages
Amharic, Somali, or other Afro-Asiatic languages
Arabic
Armenian
Chinese
Creole
English
French
German
Greek
Gujarati
Haitian
Hebrew
Hindi
Hmong
Ilocano, Samoan, Hawaiian, or other Austronesian languages
Italian
Japanese
Khmer
Korean
Malayalam, Kannada, or other Dravidian languages
Nepali, Marathi, or other Indic languages
Persian
Polish
Portuguese
Punjabi
Russian
Serbo-Croatian
Spanish
Swahili other languages of Central, Eastern, and Southern Africa
Tagalog
Tamil
Telugu
Thai, Lao, other Tai-Kadai languages
Ukrainian or other Slavic languages
Urdu
Vietnamese
Yiddish, Pennsylvania Dutch or other West Germanic Languages
Yoruba, Twi, Igbo, or other languages of Western Africa
Other Asian languages
Other Indo-European languages
Other
Graduation Year
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
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1968
1969
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1971
1972
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1977
1978
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1980
1981
1982
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1987
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1989
1990
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2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
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2014
2015
2016
2017
2018
2019
2020
2021
Employment Status
Full-Time (32 hours or more hours per week)
Part-Time (less than 32)
Unemployed and looking for work
Unemployed and NOT looking for work
Contractor/Consultant
Student
Retired
Homemaker
Disabled, not able to work
Other
Prefer not to answer
Gender Identity - Other
Employment Status - Other
Racial Background - Other
Spoken Languages - Other
Are you a licensed provider?
Choose...
I am not a licensed provider
Acupuncturist
Certified Addiction Counselor
Chiropractor
CNS
DDS
Dietitian
DO
LCSW
LPC
LPN
Massage Therapist
MD
Mental Health Counselor
NP
Nutritionist
PA
Pharm Tech
PharmD
Podiatrist
Psychologist
Resident/Fellow
RN
Substance Abuse Counselor
Other
Licensed Provider Other
Highest Degree Earned
Choose...
AS/AAS
BA/BS
MA/MS
MPH
MD
PhD/EdD
DrPH
ScD
PharmD
DDS
DO
Not Applicable/No Degree
Initial License Year
Choose...
Choose...
NA
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
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1958
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1961
1962
1963
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1967
1968
1969
1970
1971
1972
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1974
1975
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1977
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1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
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2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
What percentage of your time is devoted to each of the following areas?
Percentage of Time Spent in Patient Care
Percentage of Time Spent in Research
Percentage of Time Spent in Teaching/Instruction
Percentage of Time Spent in Administration
Security question
Required