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Certified Provider Details:
| PROVIDER NUMBER: | 490001 |
| AGENCY NAME: | Family Counseling Connection |
| CONTACT NAME: | Frank Fazzolari |
| ADDRESS: | 1021 Quarrier Street, Suite 414 |
| CITY: | Charleston |
| STATE: | WV |
| ZIP: | 25301 |
| PHONE: | (304) 340-3676 |
| WEB SITE: | www.familycounselingconnection.org |
| EMAIL ADDRESS: | |
| BSW/MSW NAME: | Janice Hamon |
| DUE TO RECERTIFY DATE: | 7/1/2010 |
| COMMENTS: |