MEDICARE: NLW YOUTH DEVELOPMENT PROGRAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1639037070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NLW YOUTH DEVELOPMENT PROGRAM

Provider Business Mailing Address
First Line	:	2504 SAINT PAUL ST STE 1
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-4606
Country	:	US
Telephone Number	:	443-360-8936
Fax Number	:

Provider Business Practice Location Address
First Line	:	2504 SAINT PAUL ST STE 1
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-4606
Country	:	US
Telephone Number	:	443-360-8936
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NICKEL LATANYA WALSTON
Credential	:
Telephone Number	:	443-303-6615

Provider Enumeration Date	:	01/14/2026
Last Update Date	:	01/14/2026

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