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Membership/Directory Application

Membership/Directory Application

MEMBERSHIP DIRECTORY INFORMATION

First Name:*

Middle Name:

Last Name:*

Credentials*

Clinic / Business Name:*

Address:

City:*

State:

Zip:*

Country:*

Phone:*

Personal email (for internal MAPS use only):*

Clinic Email:

Website:*

Where did you receive your medical training? (Please specify the university, college, or certification program):*

University

Name:

Medical School

Name:

Residency

Name:

Specialty

Name:

Other

Name:

About: Enter additional information about your practice here

List All Services Provided (enter each Service in new line):

Diagnoses Treated:

Description of Practice:

Type of Clients:*

Children Adults Children and Adults

Do you take Healthcare Insurance?*

Yes No

Do you conduct virtual appointments for patients?*

Yes No

Select State(s) for Virtual Appointments:*

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

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

Percentage of ASD Patients in your Practice:

Treatments Offered :

TruDOSE™

HBOT

IntellxxDNA^®

IVIG

Detoxification

Other

Specialty : *

Mito

PANS/PANDAS

Lyme

Seizures

ADHD

Allergies/Eczema

Autism Spectrum Disorders

Mast Cell

Gastrointestinal conditions

Motor Disorders

Anxiety/Depression/PTSD

Iatrogenic Disorders

POTS

Ehlers-Danlos syndrome

Down’s Syndrome

Adults

Other

Clinic Social Media:

Facebook

Twitter

Instagram

Linkedin

Upload Profile Image

Corporate Partners

Hopewell Pharmacy and Compounding Center

A Major Difference

Alight Health Formulas

Alletess Medical Laboratory

ASPIRE Alliance to Solve PANS & Immune-Related Encephalopathies

Aspire Nutrition

Autism Diagnostics Lab

BrainMaster Technologies

Carolina Functional Neurology Center

Children's Health Defense

Communication 4 ALL

Doctor's Data, Inc.

Ecological Formulas & Cardiovascular Research

Empowered Voices

Functional Genomic Analysis

Galaxy Diagnostics

Healthy Kids Happy Kids

International Lyme & Associated Diseases Society

LOOK. FOUNDATION INC

LymeCore Botanicals

Master Supplements Inc

Maverick Medical Ventures

Medi Air Purifier

Mosaic Diagnostics

NeuroNeeds, LLC

New Beginnings Nutritionals

Nordic Naturals

PD Labs Compounding Pharmacy

Pennsylvania Coalition for Informed Consent (PCIC)

Researched Nutritionals

Results RNA LLC

RSM Diagnostics Lab

Superior Mobile | Superior Express Labs

The Wellness Blanket/Rapha Wellness

Thought Leadership & Innovation Foundation

US BioTek Laboratories

Vertisis Custom Pharmacy

Vibrant Health Systems, Inc.

Wellness Pharmacy

We are a group of professionals who offer a Comprehensive Education & Fellowship to Medical Professionals for the care of children with Autism Spectrum Disorders and related chronic complex conditions.

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In support of improving patient care, this activity has been planned and implemented by Continuing Education, Inc. and MEDICAL ACADEMY OF PEDIATRIC AND SPECIAL NEEDS. Continuing Education. Inc. is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

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First Name*

Last Name*

Email Address*

Who are you? *

Credential(s) (N/A for parents)

How did you hear about us?