Provider Demographics
NPI:1265211239
Name:MODICA, TIFFANY MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:MARIE
Last Name:MODICA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 ADAMS AVE STE 214
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4865
Mailing Address - Country:US
Mailing Address - Phone:714-957-1973
Mailing Address - Fax:
Practice Address - Street 1:1700 ADAMS AVE STE 214
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4865
Practice Address - Country:US
Practice Address - Phone:714-957-1973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2024-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61475566101YM0800X
WA61475566101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health