Healthcare Provider Details

I. General information

NPI: 1710805791
Provider Name (Legal Business Name): BOLD SPEECH THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MAIN ST
YAZOO CITY MS
39194-4010
US

IV. Provider business mailing address

190 EOLA DR
YAZOO CITY MS
39194-8203
US

V. Phone/Fax

Practice location:
  • Phone: 601-456-0023
  • Fax: 601-510-9065
Mailing address:
  • Phone: 601-456-0023
  • Fax: 601-510-9065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER ANN MELTON
Title or Position: OWNER
Credential: CCC-SLP
Phone: 601-456-0023