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Health
Behavioral Health Agencies
P.O. Box 47877
Olympia, WA 98504-7877
360-236-4700
Revenue: 0597649550
Administrator Change Notification Form
Behavioral Health Agency Service Provider
Name of Agency: Grant Integrated Services - Moses Lake Main
Owner Name: Grant County
Credential Number 60872648
As the newly appointed Ad�
,ministrator of the above agency, I affirm that I amresponsible for performing the ke.
responsibi I ties as of the date I was appointed Administrator.
New Administrator Name: Dell Anderson, M.Ed, LIVIFIC Title: Executive Director
New Administrator Signature Date of Signature 1 OJ4119
Date, Appointed: 10/1/19 Administrator's Email: Administrator's Telephone:
daanderson@grantcountywa,gcv �(509) 765-9239
PrintedName of Governing Body Member Submitting Form: Title:
Tom Taylor Board of County Commissioners, Chair
Signat
Uf Date of Signature'.
A
'Mailing Address:
PO Box 37
City State Zip Code
Ephrata WA 988.23
Email, Phone: Fax:
thtaylor@grantcountywa.gov (509) 754-2011 (509) 754-6098
Within 30 days of the Administrator's appointment, send the following to the address listed above:
El This completed form,
U Criminal background check results, completed by Washington State Patrol -within the last 365 days.
0 The printout of the search at jittv Hexclusions. o ig. hhs. qov/,
DOH 611-006 July 2818