MEDICARE: MELISSA LY MS, CCC-SLP

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	235Z00000X	Speech-Language Pathologist	SP2479	ME
2	235Z00000X	Speech-Language Pathologist	22283	CA

General Provider Information

NPI Number	:	1265834873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA LY MS, CCC-SLP

Provider Business Mailing Address
First Line	:	24328 VERMONT AVE
Second Line	:
City	:	HARBOR CITY
State	:	CA
Zip	:	90710-2314
Country	:	US
Telephone Number	:	424-250-9615
Fax Number	:

Provider Business Practice Location Address
First Line	:	24328 VERMONT AVE STE 318
Second Line	:
City	:	HARBOR CITY
State	:	CA
Zip	:	90710-2314
Country	:	US
Telephone Number	:	424-250-9615
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2014
Last Update Date	:	11/16/2021

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