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Certified Provider Details:
| PROVIDER NUMBER: | 490046 |
| AGENCY NAME: | Mt. State University Social Work Dept. |
| CONTACT NAME: | Dr. Everett Lilly |
| ADDRESS: | Box 9003 |
| CITY: | Beckley |
| STATE: | WV |
| ZIP: | 25802 |
| PHONE: | |
| WEB SITE: | |
| EMAIL ADDRESS: | casiers@mountainstate.edu |
| BSW/MSW NAME: | Karen Cummings Lilly |
| DUE TO RECERTIFY DATE: | 7/1/2020 |
| COMMENTS: |