Nutrition Provider Sign-Up

First Name:*

Last Name:*

Email:*

Phone Number*

State:*

Zip Code:*

Date of Birth*

What is your role?*

Select all that are appropriate

Registered Dietitian Nutritionist (RDN)

Dietetics Technician Registered (DTR)

Certified Clinical Nutritionist (CCN)

Certified Nutrition Specialist (CNS)

Licensed Nurtitionist (LN)

Non-Licensed Nutritionist

Other

Years of Experience*

Qualifications

Click + to add multiple State Licenses

License State*

License Number*

License Expiration*

DEA Number

Add if applicable.

NPI Number

Add if applicable.

Additional Certifications

Seperate certitifcations by a comma. You may enter up to 5.

Write below exactly how you would like your name to be displayed.

Example: Parker Condit, MS, RDN

Add Your Education

Click "Add" to add multiple Education/Degrees.

College/University Name	Degree	Year of Graduation	Actions

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What are your Specialties?*

You may select up to 5

Other Specialties

Service Location

Do you offer virtual visits?*

Yes

No

Do you want to offer virtual visits on Modo Bio's platform?*

Yes

No

Do you want to recieve referrals for in-person clients from Modo Bio?*

Yes

No

What is your physical location?

Street Address Address Line 2 City State ZIP Code

Provider Bio

Why did you get into this field? What is your general philosophy when it comes to nutrition and dietetics? Describe your ideal client. Anything else you would like potential clients to know.

Website

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