           |
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Certified Provider Details:
| PROVIDER NUMBER: | 490106 |
| AGENCY NAME: | Intensive Trauma Therapy, Inc. |
| CONTACT NAME: | Carrie Downey |
| ADDRESS: | 314 Scott Avenue |
| CITY: | Morgantown |
| STATE: | WV |
| ZIP: | 26508 |
| PHONE: | (304) 291-2912 |
| WEB SITE: | www.traumatherapy.us |
| EMAIL ADDRESS: | carrie@traumatherapy.us |
| BSW/MSW NAME: | Carrie Downey MSW |
| DUE TO RECERTIFY DATE: | 7/1/2012 |
| COMMENTS: |