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Certified Provider Details:
| PROVIDER NUMBER: | 490021 |
| AGENCY NAME: | DHHR-BCF |
| CONTACT NAME: | Susan Richards |
| ADDRESS: | Division of Training 350 Capitol Street B-18 |
| CITY: | Charleston |
| STATE: | WV |
| ZIP: | 25301 |
| PHONE: | |
| WEB SITE: | www.wvdhhr.org |
| EMAIL ADDRESS: | |
| BSW/MSW NAME: | Clifford Terrell |
| DUE TO RECERTIFY DATE: | 7/1/2012 |
| COMMENTS: |