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General NPI Number Information
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NPI Number | 1366995078
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Entity Type | Individual
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Provider Name | DR. ANDREA WAGNER
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Gender | Female
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Dates
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Enumeration Date | 07/28/2016
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Last Update Date | 05/23/2024
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Provider Practice Location Address
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Address Line | 456 OLD NEWPORT BLVD
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City | NEWPORT BEACH
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State | CA
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Zip | 92663-4211
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Country | US
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Telephone | 949-447-8257
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Fax |
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Provider Business Mailing Address
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Address Line | 456 OLD NEWPORT BLVD
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City | NEWPORT BEACH
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State | CA
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Zip | 92663-4211
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Country | US
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Telephone | 949-447-8257
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TM1800X
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Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
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License Number |
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103TF0200X
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Taxonomy Name | Forensic Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 32730
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number |
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License Number State | CA
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