Provider Demographics
NPI:1518277300
Name:BOLDEN, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 SEPULVEDA BLVD.
Mailing Address - Street 2:323 NORTH PRAIRIE AVEENUE
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301
Mailing Address - Country:US
Mailing Address - Phone:310-751-5344
Mailing Address - Fax:310-846-2100
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:323 NORTH PRAIRIE AVENUE
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:310-846-2100
Practice Address - Fax:310-751-5344
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACATC - B1109231901101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)