Provider Demographics
NPI:1821666744
Name:WESLEY, NICHOLAS MICHAEL
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:WESLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5709 ANTHONY AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-3636
Mailing Address - Country:US
Mailing Address - Phone:267-424-3161
Mailing Address - Fax:
Practice Address - Street 1:1208 E CHURCHVILLE RD STE 300
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-3485
Practice Address - Country:US
Practice Address - Phone:410-893-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MDLGP15436101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician