           |
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Certified Provider Details:
| PROVIDER NUMBER: | 490094 |
| AGENCY NAME: | WVFRIS |
| CONTACT NAME: | Debra Lopez-Bonasso |
| ADDRESS: | 112 Braddock Street |
| CITY: | Fairmont |
| STATE: | WV |
| ZIP: | 26554 |
| PHONE: | |
| WEB SITE: | www.fris.org |
| EMAIL ADDRESS: | fris@labs.net |
| BSW/MSW NAME: | Harriet Sutton, MSW |
| DUE TO RECERTIFY DATE: | 7/1/2010 |
| COMMENTS: |