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Certified Provider Details:
| PROVIDER NUMBER: | 490029 |
| AGENCY NAME: | WV Assoc of Alcoholism/Drug Abuse |
| CONTACT NAME: | Angela Wagner |
| ADDRESS: | RR 4 Box 3013 |
| CITY: | Clarksburg |
| STATE: | WV |
| ZIP: | 26301 |
| PHONE: | (304) 624-1786 ext. 251 |
| WEB SITE: | www.naadac.org/WV/ |
| EMAIL ADDRESS: | awagner@crchealth.com |
| BSW/MSW NAME: | Angela Wagner |
| DUE TO RECERTIFY DATE: | 7/1/2012 |
| COMMENTS: |