Healthcare Provider Details

I. General information

NPI: 1558288084
Provider Name (Legal Business Name): ELLE MOON GATEWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3844 E PIMA ST
TUCSON AZ
85716-3308
US

IV. Provider business mailing address

3844 E PIMA ST
TUCSON AZ
85716-3308
US

V. Phone/Fax

Practice location:
  • Phone: 520-477-7752
  • Fax: 520-505-6577
Mailing address:
  • Phone: 520-477-7752
  • Fax: 520-505-6577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberTSLP17538
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: