=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104717867
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPEECH LANGUAGE PROS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2025
-----------------------------------------------------
Last Update Date | 07/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13500 SUTTON PARK DR S STE 801
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32224-5290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-834-0775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13500 SUTTON PARK DR S STE 801
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32224-5290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-834-0775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/SLP
-----------------------------------------------------
Name | MRS. ANTWIWA HYMAN
-----------------------------------------------------
Credential | CCC-SLP
-----------------------------------------------------
Telephone | 904-472-1431
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------