HomeMy WebLinkAbout*Other - GRISea I t h
Behavioral Health Agencies
P.O. Box 47877
Olympia, WA 98504-7877
360-236-4700
Revenue: 0597649550
M
AdministratorChange �+Io#ificati"on Form
Behavioral Health Agency Service Provider
Name of Agency, Grant Integrated Services - Royal City
Owner Name', Grant County
Credential Number 60872653
As, the newly appointed Administrator, of the above agency, I affirm that I am responsible for performing the key
responsibilities as of the date 1, was appointed Administrator.
New Administrator Name: Dell Anderson, M. Ed, LI HC
Title-, Executive Director
Date of Signature 10/4119
New Administrator Signature
Date Appointed: 10/1/19 Administrator's Email: Administrator's Telephone:
daan.derson@grantcountywa,.gc v (509)'765-9239
Printed Name of Governing Body Member Submitting Form: Title:
Tom Taylor Board of County Commissioners, Chair
Signature: Date -of St nature,
14
Mailing Address,
PO Box 37
City
State
Zip Code
Ephrata
WA
9882.3
Email:
Phone:
Fax:
thtaylor@gran'tcountywa.gov
(50-9) 754-2,011
1(509) 754-6098
Within 30 days of the Administrator's appointment.., send the following tothe address listed above.*
0 This completed form.
El Criminal background check results, completed by Washington State Patrol within the last 3.65 days..
n The printout of the search at h.ttp://exclusions.oig.hhs..gov/.
DOH 611-006 July 2018