Healthcare Provider Details

I. General information

NPI: 1366995078
Provider Name (Legal Business Name): DR. ANDREA WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 OLD NEWPORT BLVD
NEWPORT BEACH CA
92663-4211
US

IV. Provider business mailing address

456 OLD NEWPORT BLVD
NEWPORT BEACH CA
92663-4211
US

V. Phone/Fax

Practice location:
  • Phone: 949-447-8257
  • Fax:
Mailing address:
  • Phone: 949-447-8257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number32730
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: