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General NPI Number Information
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NPI Number | 1770314270
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Entity Type | Organization
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Legal Business Name | ANDREA M WAGNER PSYCHOLOGIST PC
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Dates
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Enumeration Date | 08/08/2024
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Last Update Date | 12/11/2025
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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 | 949-780-9025
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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 | 949-209-0357
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Authorized Official
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Title or Position | OWNER
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Name | DR. ANDREA MARIE WAGNER
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Credential | PSY.D.
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Telephone | 949-782-2254
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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