MEDICARE: TIFFANY MARIE WILLINGHAM SUDRC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	175T00000X	Peer Specialist	18573	CA

General Provider Information

NPI Number	:	1699507814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY MARIE WILLINGHAM SUDRC

Provider Business Mailing Address
First Line	:	14400 NEWPORT AVE APT 91
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92780-5624
Country	:	US
Telephone Number	:	949-343-6566
Fax Number	:

Provider Business Practice Location Address
First Line	:	671 GOVERNOR ST
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-2504
Country	:	US
Telephone Number	:	949-343-6565
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2024
Last Update Date	:	12/16/2025

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