# SELF-EXPRESSION TEEN THEATER

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1538255732
- **Authorized official:** MR. CHARLES MUHAMMAD MA, CHES, CTCC, OCPS (EXECUTIVE DIRECTOR)
- **Authorized official phone:** (419) 242-2255

## Contact information

- **Practice address:** 1001 INDIANA AVE, SUITE 203-204, TOLEDO, OH 43607-4084
- **Practice address phone:** (419) 242-2255
- **Practice address fax:** (419) 242-3152
- **Mailing address:** 1001 INDIANA AVE, SUITE 203-204, TOLEDO, OH 43607-4084
- **Mailing address phone:** (419) 242-2255
- **Mailing address fax:** (419) 242-3152

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 251K00000X | Public Health or Welfare Agency | — | NULL | Yes |

## Other

- **Enumeration date:** 10/05/2006
- **Last updated:** 08/22/2020