Healthcare Provider Details

I. General information

NPI: 1699507814
Provider Name (Legal Business Name): TIFFANY MARIE WILLINGHAM SUDRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

671 GOVERNOR ST
COSTA MESA CA
92627-2504
US

IV. Provider business mailing address

14400 NEWPORT AVE APT 91
TUSTIN CA
92780-5624
US

V. Phone/Fax

Practice location:
  • Phone: 949-343-6565
  • Fax:
Mailing address:
  • Phone: 949-343-6566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number18573
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: