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Behavioral Health Agencies
P.O. Box 47877
Olympia, WA 98504-7877
360-236-4700
Revenue-, 1 0597649550
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Administrator Change Notification Form
Behavioral Health Agency Service Provider
Name of Agency: Grant Integrated Services - Grand Coulee
Owner Name: Grant County
CredentialNumber 60872650
As the newly appointed Administrator of the above'agency, I affirm that I am responsible for performing the key
responsibilities as of the date I was appointed Administrator.
New Administrator Name., Dell Anderson, M.Ed, LMHC
Title: Executive Director
New Administrator Signature
Date of Signature 1014/19
Date Appointed: 10/1 /19
Administrator's Emall:
Administrator's Telephone:
daanderson@gran'tcountywa,.g
(509) 765-9239
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Printed Name of Governing Body Member Submitting Form:
Title:
Tom Taylor
Board of County Commissioners, Chair
Signatur
Date of Signature:
Mailing Address:
PO Box 37
City
State
Zip Code
Ephrata
WA
98823
Email:
Phone:
Fax:
th;taylor@g!rantcountywa.gov
(609) 754-2011
(509) 754-6098
Within 30 days of the Administrator's appointment, send the following to the address listed above:
0 This completed form,
U Criminal background check results, completed by Washington State Patrol within the last 365 days..
OThe printout of the search at http://exclusions,oig.hhs.gov/.
DDH 611-006 July 2018