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[]
["ADMIS Provider Details Form"]
["Provider Name:",null,"Start Date:",null,null,"Liaison First Name:"]
["Sub-provider(s) ",null,"Start Date:",null,null,"Liaison Last Name:"]
["Funding Source (select from drop down)",null,"Provider Tax ID:",null,null,"Liaison Email Address:"]
["Provider Type (select from drop down)",null,"Provider Website:"]
[]
["MAT Type:\nAdolescent Residential, Incarceration, Juvenile Drug Court, Medical Detox, Observational Detox, Outpatient, Partial Day, Residential, SWS",null,null,null,null,"Service Type:\nMethadone; Buprenorphine - Oral; Buprenoprine - Injectable; Buprenophine - Implant; Naltrexone - Injectable; Naltrexone - Oral"]
[" "]
["PHYSICAL ADDRESS",null,null,null,null,"MAILING ADDRESS"]
["Address Line 1:",null,null,null,null,"Address Line 1:"]
["Address Line 2:",null,null,null,null,"Address Line 2:"]
["City:",null,null,null,null,"City:"]
["State:",null,null,null,null,"State:"]
["Zip Code:",null,null,null,null,"Zip Code:"]
["County:",null,null,null,null,"County:"]
["Phone Number:",null,null,null,null,"Fax Number: "]

{"sheet":"Data","index":1,"n_rows":11,"n_cols":4,"rows_kept":11,"cut":false,"hidden":false,"merged":[]}
["Methodone Clinic",null,null,"Methadone"]
["Treatment Clinic",null,null,"Buprenorphine - Oral/Sublingual/Buccal (e.g. Suboxone, Buprenorphine, Naloxone)"]
["Drug Court",null,null,"Buprenorphine - Injectable (e.g. Sublocade)"]
[null,null,null,"Buprenorphine - Implant (e.g. Probuphine) "]
[null,null,null,"Naltrexone - Injectable (e.g. Vivitrol)"]
[null,null,null,"Naltrexone - Oral "]
["DBHS"]
["SOR"]
["SOR2"]
["Other "]
["Other - MAT"]