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State of North Carolina <br />Division of Social Services <br />Contract Application <br />Page 2 of 7 <br />E. Contract Identification: <br />1. Provider <br />a. Name of Contract Administrator Neil Pederson <br />Tel. # :967-8211 <br />b. Name of Pro~am Contact Person: Jeff Reilly <br />Tel. #: 967-8211 <br />c. Program Name, Location and Mailing Address: <br />750 S. Merritt Mill Rd. <br />d. Additional Service Delivery Sites: <br />e. Status : (~ Public ()Private, non-profit <br />( )Private, for Profit ( )Individual <br />f. Provider Contract ID #: hRF,2(1 <br />2. County 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 />Gwen Price or Valerie Collins-Russell <br />Tel. #: 245-2800 <br />c. Address of County Department of Social Services: <br />300 W Trvon Street _ <br />Hillsborough, NC 27278 <br />