Healthcare Provider Details

I. General information

NPI: 1316800774
Provider Name (Legal Business Name): MOONFLOWER PEDIATRIC THERAPIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 W 24TH ST STE 106
YUMA AZ
85364-9280
US

IV. Provider business mailing address

3860 W 24TH ST STE 106
YUMA AZ
85364-9280
US

V. Phone/Fax

Practice location:
  • Phone: 928-509-9322
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: FABIOLA ROMERO GONZALEZ
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: M.S., CCC-SLP
Phone: 928-509-9322