Change of Name or Address/Duplicate License Request for Health Licensees

To change your name you must submit request in writing.

To change your address you must either submit in writing or via the Internet.

To change your address online go to www.michigan.gov/elicense. If you require a new license to be issued with the new information you can request and pay for a duplicate license with a credit card. A new license is not issued automatically.

You can complete the Data Change/Duplicate License Request Form 

  • Fax to 517-335-2044 (no new license issued) or
  • Mail the form to LARA/BPL/Licensing Division, PO Box 30670, Lansing MI 48909.
    Include $10 fee if new license is required