MEDICARE: DR. ANDREA M WAGNER PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0400X	Addiction (Substance Use Disorder) Psychologist	32730	CA
2	103TR0400X	Rehabilitation Psychologist	5083	CT
3	103TR0400X	Rehabilitation Psychologist	32730	CA
4	103TC0700X	Clinical Psychologist	32730	CA
5	103TC0700X	Clinical Psychologist	5083	CT
6	103TM1800X	Intellectual & Developmental Disabilities Psychologist	32730	CA

General Provider Information

NPI Number	:	1366995078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREA M WAGNER PSY.D.

Provider Business Mailing Address
First Line	:	456 OLD NEWPORT BLVD
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-4211
Country	:	US
Telephone Number	:	949-447-8257
Fax Number	:

Provider Business Practice Location Address
First Line	:	456 OLD NEWPORT BLVD
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-4211
Country	:	US
Telephone Number	:	949-447-8257
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2016
Last Update Date	:	05/09/2026

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