Healthcare Provider Details

I. General information

NPI: 1801723564
Provider Name (Legal Business Name): TIFFANY MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 W PEARL ST
ANAHEIM CA
92801-5941
US

IV. Provider business mailing address

1320 W PEARL ST
ANAHEIM CA
92801-5941
US

V. Phone/Fax

Practice location:
  • Phone: 714-780-1174
  • Fax:
Mailing address:
  • Phone: 714-780-1174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21347
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: