DPH: Requests for Name or Address Change

Requests for Name or Address Change

For the licensee's or applicant's protection, requests for name or address changes must be submitted in writing directly from the licensee or applicant.  The request may be submitted by emailing the Department and providing the licensee's name, license number, profession, date of birth, the last 4 digits of the licensee's U.S. Social Security number and the requested change.

The request may be submitted via U.S. Mail by completing a request form and submitting it in accordance with the directions on the form.

Please note that a new license will not be generated until after the license has been renewed.





Content Last Modified on 1/9/2015 7:52:13 AM