Provider Demographics
NPI:1699507814
Name:WILLINGHAM, TIFFANY MARIE (SUDRC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:WILLINGHAM
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14400 NEWPORT AVE APT 91
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-5624
Mailing Address - Country:US
Mailing Address - Phone:949-343-6566
Mailing Address - Fax:
Practice Address - Street 1:671 GOVERNOR ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2504
Practice Address - Country:US
Practice Address - Phone:949-343-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18573101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)