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Name Change for Individual Practitioners

Required Documentation

To change the name on your license, you will need to provide documentation that the change legally occurred.

You must submit a copy of a government issued ID or legal document approving or indicating your name change, such as a marriage license, a court petition for name change, or a certificate of naturalization.

For changes to your first-name only, please attach a copy of a court petition for name change or certificate of naturalization in addition to a government issued ID.


Application

Documents submitted with your application will not be returned. Keep a copy of your completed application and all attachments.

During License Renewal

If you are changing your name before a renewal, then you will not need to pay a fee. Please send your request for a name change with all documents mentioned above and a copy of your ID via our secure webform. When your license is renewed, it should reflect the new name.

All Other Times

You can download a copy of the Notice of Change and Duplicate License Request (PDF) form. There is no fee required for the name change, however you will be charged $25 for the issuing of a new license with the new name.

You may either submit the request and documentation via secure webform, or you can mail all documents to the address listed on the form.


Change of Contact Info

You may also choose to update your mailing address, phone number, and email address at the same time by completing those fields in the form.

You can also update your contact info online if you prefer.


Getting a New Copy of Your License

If you need an official copy of your license after your name has been changed, you can order a duplicate license online.


Processing Time

Name changes can take multiple weeks to receive and process.

If you need to renew your license concurrently with a name change, please complete the name-change process before renewing your license.

For assistance, please contact customer service, or call us at (800) 803-9202.