Provider Demographics
NPI:1770314270
Name:ANDREA M WAGNER PSYCHOLOGIST PC
Entity type:Organization
Organization Name:ANDREA M WAGNER PSYCHOLOGIST PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-447-8257
Mailing Address - Street 1:456 OLD NEWPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4211
Mailing Address - Country:US
Mailing Address - Phone:949-447-8257
Mailing Address - Fax:
Practice Address - Street 1:456 OLD NEWPORT BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4211
Practice Address - Country:US
Practice Address - Phone:949-780-9025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANDREA M WAGNER PSYCHOLOGIST PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-08
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder