MEDICARE: MELISSA CARYLE VERCAUTREN

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	SP22519	CA

General Provider Information

NPI Number	:	1518824986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA CARYLE VERCAUTREN

Provider Business Mailing Address
First Line	:	115 W ALLEN AVE
Second Line	:
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-1437
Country	:	US
Telephone Number	:	909-971-8206
Fax Number	:

Provider Business Practice Location Address
First Line	:	1629 HOLLY OAK ST
Second Line	:
City	:	LA VERNE
State	:	CA
Zip	:	91750-3914
Country	:	US
Telephone Number	:	909-971-8206
Fax Number	:

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

Provider Enumeration Date	:	01/07/2026
Last Update Date	:	01/07/2026

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Directions to “ MELISSA CARYLE VERCAUTREN ” Practice Location

Language	Start Address	Practice Location

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