Board of Registration for the Healing Arts

Change of Address

Please provide the Missouri State Board of Registration for the Healing Arts with any change in your business and/or home address. Please use the form below to report address changes and/or remove address(es) from your record and click submit.

Click here to report a change of name.

Name as it appears on your license

Last Name: (Required)
First Name: (Required)
Middle Initial:
License Number: (Required)
Email:
Effective Date:
Changes dated in the future won't be changed until the date noted.
Please indicate whether you want information sent to your home or business address. * Required	Home Business

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New Business Address

Street (line 1):
Street (line 2):
City:
State:
Zip Code:
Telephone Number: (Please include area code)

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New Home Address

Street (line 1):
Street (line 2):
City:
State:
Zip Code:
Telephone Number: (Please include area code)

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New Additional Location Address

Street (line 1):
Street (line 2):
City:
State:
Zip Code:
Telephone Number: (Please include area code)

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Remove the Following Address from my Record

Street (line 1):
Street (line 2):
City:
State:
Zip Code:

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Please type the numbers displayed above in the box below.

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