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10 <br />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 Kathv 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 />d. Additional Service Delivery Sites: <br />e. Status : OPublic (X) Private, non-profit <br />( )Private, for Profit ( )Individual <br />f: Provider Contract ID #: <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 />