Committee of Psychologists

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Change of Address

Please provide the Missouri State Committee of Psychologists with any change in your home address. Please use the form below to report address changes, and click submit.

You must complete the form in its entirety or no changes will be made.

You must fill out all required fields.
Name as it appears on the 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, and a license reflecting the new address will be mailed close to the effective date of the change.
Old Email:
New Email:
New Business Address
Street (line 1):
Street (line 2):
City:
State:
Zip Code:
Telephone Number:
(Please include area code)
New Home Address
Street (line 1):
Street (line 2):
City:
State:
Zip Code:
Telephone Number:
(Please include area code)
New Branch Address
Street (line 1):
Street (line 2):
City:
State:
Zip Code:
Telephone Number:
(Please include area code)
Code
Please type the numbers displayed above in the box below.