Name Change

Make sure to have the following information before you begin the name change process:

Your first and last name;
Your social security number;
Your PT/PTA license number;
A Legal Document in PDF format that indicates the name change that can be uploaded;
A current Visa or MasterCard account;
The expiration date of the Visa or MasterCard account.

If you require an updated wall certificate it will cost $20.00. An updated wall certificate will be mailed to you once the payment has been approved.

All information entered will be encrypted, so your data will be transmitted safely and securely.

While you are in the online form please do NOT use the back button in your browser. If at any time you wish to exit the online form, please click the "Exit" button located at the bottom of the page.

Please enter your information below to log into the online form. Contact the board if you have any questions.


Last Name	Last 4 Digits of SSN	License Number
		If you have a 3 digit license number, add a preceding zero.