HomeMy WebLinkAbout*Other - GRIS (005).t1iHealth
Behavioral HeafthAgencles
P.0., Box 47877
Olympia, WA 98504-7877
360-236-4700
Revenue -.05,97649550
Administrator Change Notification Form
Behavioral Health Agency Service Provider
Name of Agency: Grant Integrated Services - Quincy
Owner Name: Grant County
Credential Number 60872652
As the, newly appointed Administrator, of the above, agency, I aff irmthat I am responsible for performing the key
responsibifit"
i ies as of the date I was appointed Administrator.
New, Administrator Name: Dell Anderson, M.Ed, LMH C Title, Executive Director
New Administrator Signature Date of Signature 10/4/19
Date Appointed.- 10/1/19
Administrator's Email,-, Administrator's Tele phon e:
-,-,daanderson@grant�countywa.,gqv (509) 765-9239
'Printed Name of Governing Body Member Submitting Form: Title:
Tom Taylor Board of County Commissioners, Chair
Signatur
Date of Signature:
LO C'? /1 '9
Mailing Address.
PO Box 37
City
Ephrata
State
... .. ..... .... .. ......
Zip Code
WA
98823
Email:
Phone:
Fax:
thtayfor@grantcountywa.gov
(509) 754-2,011(09)74
. ............ . ]56
-6098
Within 30 days of the Administrator's appointment.,send the following to the address fisted above,
0 This completed form,
0 Criminal background check results, completed by Washington State Patrol within
the last 365 days.
0 The printout of the search at h,ttp://exclusions.oiq.hhs
DOH 611-006 July 2018