HomeMy WebLinkAbout*Other - GRIS (004)i'MOdo 11(n) Pate Pethloweld of
- Health.
Behavioral Health Agencies
R.0. Box 47877
Olympia, WA 98504-7877
360-2-36-4700
Revenue: 0597649550
Adm ininstrator Change Note#N+ca#iun Form
Behavioral Health Agency Service Provider
Name of Agency: Grant I nteg rated Services .- Mattawa
Owner Name, Grant County
Credential Number 60872651
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, LG
Title: Execufive Director
New Administrator Signature
Date of Signature 10/4119
Date Appointed-, 10/1/19
Administrator's Email."
Administrator's Telephone-
daanderson@grant,countywa.gcv
(509) 765-9239
Printed Name of Governing Body Member Submitting Form,
'Title,
Tom Taylor
Board of County Commissioners, Chair
Signature,
Date of Si nature:
Mailing Address:
PO Box 37
City
State
Zip Code
Ephrata
WA
98823
Email:
Phone:
Fax:
tht.aylor@grantcountywa.gov
(509) 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.
OCriminal background check results, completed by'lash ington State Patrol within the last 365 days.
0, The printout of the search at http-.//exclusions.oig..hhs.,qov/.
DOH 611-006 July 2018