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State of North Carolina <br /> Division of Social Services <br /> Contract Application Page 2 of 7 <br /> E. Contract Identification: <br /> 1. Provider <br /> a. Name of Contract Administrator Kathy Bryan <br /> Tel. # : 732-8124 <br /> b. Name of Program Contact Person: Antonia Pedroza <br /> Tel. #: 732-8124 <br /> c. Program Name, Location and Mailing Address: <br /> 500 Valley Forge Rd. <br /> Hillsborough,NC 27278 <br /> d. Additional Service Delivery Sites: <br /> e. Status : ( ) Public (X) Private,non-profit <br /> ( ) Private, for Profit( ) Individual <br /> f. Provider Contract ID#: 69F50 <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: Gwen Price <br /> Tel. #: 245-2800 <br /> c. Address of County Department of Social Services: <br /> 300 W Tryon Street <br /> Hillsborough,NC 27278 <br /> 8 <br />