MEDICARE: SELF-EXPRESSION TEEN THEATER

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	251K00000X	Public Health or Welfare Agency

General Provider Information

NPI Number	:	1538255732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELF-EXPRESSION TEEN THEATER

Provider Business Mailing Address
First Line	:	1001 INDIANA AVE
Second Line	:	SUITE 203-204
City	:	TOLEDO
State	:	OH
Zip	:	43607-4084
Country	:	US
Telephone Number	:	419-242-2255
Fax Number	:	419-242-3152

Provider Business Practice Location Address
First Line	:	1001 INDIANA AVE
Second Line	:	SUITE 203-204
City	:	TOLEDO
State	:	OH
Zip	:	43607-4084
Country	:	US
Telephone Number	:	419-242-2255
Fax Number	:	419-242-3152

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. CHARLES MUHAMMAD
Credential	:	MA, CHES, CTCC, OCPS
Telephone Number	:	419-242-2255

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	08/22/2020

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Directions to “SELF-EXPRESSION TEEN THEATER ” Practice Location

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