MEDICARE: ANDREA M WAGNER PSYCHOLOGIST PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
2	103T00000X	Psychologist
3	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1770314270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDREA M WAGNER PSYCHOLOGIST PC

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	:	949-209-0357

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	:	949-203-6158

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ANDREA MARIE WAGNER
Credential	:	PSY.D.
Telephone Number	:	949-447-8257

Provider Enumeration Date	:	08/08/2024
Last Update Date	:	05/09/2026

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