Healthcare Provider Details

I. General information

NPI: 1821666744
Provider Name (Legal Business Name): NICHOLAS MICHAEL WESLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 E CHURCHVILLE RD STE 300
BEL AIR MD
21014-3485
US

IV. Provider business mailing address

5709 ANTHONY AVE
BALTIMORE MD
21206-3636
US

V. Phone/Fax

Practice location:
  • Phone: 410-893-4600
  • Fax:
Mailing address:
  • Phone: 267-424-3161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP15436
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: