Division of Developmental Disabilities Services / DDDS Authorized Provider Committee Woodbrook Professional Center / Developmental Disabilities Services office of the Director INTERIM APPLICATION FOR ENROLLMENT/ AUTHORIZATION OF WAIVER SERVICES PROVIDERS FOR DDDS / APS COMMITTEE / Shared Living Division / Delaware Health and Social Services Division / OF SERVICE / Developmental Disabilities Services Woodbrook Professional Center / office of Minority / Developmental Disabilities Services Office / /
Person
Jane Gallivan / / /
Position
GENERAL INFORMATION The Application / Driver / Individual Proprietor / CPA / South Governor / Director / Director Initial Renewal DAY SERVICES Day Habilitation Prevocational Supported Employment RESIDENTIAL SERVICES Neighborhood Group Home Staffed Apartment Supervised Apartment Shared Living Application / Comprehensive General / Registered Nurse Services / Director Rev application/enrollment / /
AUTHORIZED PROVIDER APPLICATION AND ENROLLMENT DELAWARE MEDICAL ASSISTANCE ENROLLMENT AND DEVELOPMENTAL DISABILITIES PROVIDER AUTHORIZATION* Name of Person/Organization: DE Business License Number: