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Certified Provider Details:
| PROVIDER NUMBER: |
490024 |
| AGENCY NAME: |
CCIL |
| CONTACT NAME: |
Kristin Snyder |
| ADDRESS: |
341 Jefferson Avenue |
| CITY: |
Moundsville |
| STATE: |
WV |
| ZIP: |
26041 |
| PHONE: |
(304) 843-2306 ext. 223 |
| WEB SITE: |
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| EMAIL ADDRESS: |
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| BSW/MSW NAME: |
Kristin Snyder, LGSW |
| DUE TO RECERTIFY DATE: |
7/1/2012 |
| COMMENTS: |
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