Fellow Demographics

"Locate a Provider" Demographics

Please fill out the form below with all the information you'd like to have on your "Details" page of the IBFN "Locate a Provider" page.

If you leave an area blank, it will be omitted from the page. The information will be displayed as you provide, so please make sure it is accurate! IBFN will not be responsible for mistakes.

Name

First Name

Last Name

Fellowship Status

Select all that you currently hold.

Childhood Neurodevelopmental Disorders

Functional Neurology

Primary license type

Please list the primary health care license you currently hold. License - NOT Post-Graduate work..

Additional license(s)

Any additional professional license types you may hold. License - NOT Post-Graduate certificates

"Locate a Provider" Demographics

International Board of Functional Neurology