Provider Demographics
NPI:1811573124
Name:COSTILLA, TIFFANY L (CDCA)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:L
Last Name:COSTILLA
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:MISS
Other - First Name:TIFFANY
Other - Middle Name:L
Other - Last Name:MCMURRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:825 JUNE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-3417
Mailing Address - Country:US
Mailing Address - Phone:567-280-4531
Mailing Address - Fax:
Practice Address - Street 1:825 JUNE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3417
Practice Address - Country:US
Practice Address - Phone:567-280-4531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.176199101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)