Change of Address

Please provide us with both the old and new information when updating your address.

§ 903. Changes of Address

A. A licensed psychologist shall notify the board within 30 days, with documentation, attesting to any change of mailing and/or home address. This documentation notice shall include the psychologist's full name, license number, and the old and new addresses.

 

B. Should a psychologist be displaced to a temporary location due to an emergency, the psychologist shall notify the board within 30 days, with documentation attesting to the temporary change in mailing and/or home address. The documented notice shall include the psychologist's full name, license number, old address and new temporary address.

 
Old Information

Last Name First Name MI Suffix

License Number    

Public Address (Mandatory): Address 1 Address 2

City   State   Zip   Parish/County

Mailing address (for LSBEP use only): Address 1 Address 2

City   State   Zip   Parish/County

Email Address    

Phone numbers: Work/public   Home   Cell   Fax

New Information

Last Name First Name MI Suffix

License Number    

Public Address (Mandatory): Address 1 Address 2

City   State   Zip   Parish/County

Mailing address (for LSBEP use only): Address 1 Address 2

City   State   Zip   Parish/County

Email Address    

Phone numbers: Work/public   Home   Cell   Fax

 

 

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