Healthcare Provider Details

I. General information

NPI: 1154259547
Provider Name (Legal Business Name): EMBOLDEN YOUTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 W 95TH ST
LOS ANGELES CA
90044-5615
US

IV. Provider business mailing address

643 W 95TH ST
LOS ANGELES CA
90044-5615
US

V. Phone/Fax

Practice location:
  • Phone: 323-305-3209
  • Fax:
Mailing address:
  • Phone: 323-305-3209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. KENDRA BOLDEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 562-225-4442