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Behavioral Health Agencies
P.O. BOX 47877
Olyrnoia, WA 98504-7877
360-236-4700
Reventie :0597649550
14
Administrator Change Notification Form
0
BehaV ioral Health Agency Service Provider
Name of Agency:
Grant Integrated Services - Mattawa.
Credential Number'
BHA.FS.60872651
As the newly appointed Administrator of the above agency, I affirm that I amible-for
respons pe o
rf rming the key
responsibilities asof the date I was appointed Administrator.
New Administrator Name:
Title:
Dell Anderson
Executive Director
Ner!!Listrat,or Signature
Date of Signature
2/18/2021
DateV—Pd nted:
Administrator's Email-
Administrator's Telephone.*
10/19/2019
daanderson@grantcoUntYwa.gov
1509-764-2644
Title:
Printed Name of Governing Body Member Submitting Form:
Cindy
Chair of the Board of Comm'Issioners
Sign4ure:
Date ofSignature:
Mailing .Address,
P.O. Box 37
..--. State Zip Code
Ephrata. WA 98837
Email: Phone:
commissi o n e rs @9 n -754-2011 Ext. 2901 5 -754-6098
grantcou tywa,gov 509 09
Within 30 days of the Administrator'sappointIT) send nd the following to the address listed above:
• This completed form.,
• Criminal background check results, completed by' as ington State Patrol within the last 365 days
0 The printout of the search at.bttp-.Hexclus.ions.oiq.hhs..gov/,
DOH 611-006 July 2018
F 3 9 2021
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