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Contract Application <br />Page 2 of 7 <br />E. Contract Identification: <br />1. Provider <br />a. Name of Contract Administrator Kathy Brvan <br />Tel. # :732-8124 <br />b. Name of Pro~xam Contact Person: Antonia Pedroza <br />Tel. #: 732-8124 <br />c. Program Name, Location and Mailing Address: <br />500 Valley Forge Rd. <br />d. Additional Service Delivery Sites: <br />e. Status : ()Public (X) Private, non-profit <br />( )Private, for Profit ( )Individual <br />f. Provider Contract ID #: <br />2. Countv Department of Social Services <br />a. Name of Contract Administrator: Nancy Coston <br />Tel. # : 245-2800 <br />b. Name of Services Program Contact Person: <br />Tel. #: 245-2800 <br />Gwen Price <br />c. Address of Countv Department of Social Services: <br />300 W. Trvon Street <br />Hillsborough, NC 27278 <br />