Provider Demographics
NPI:1114449949
Name:KAEMMERER, TOBIAS D (PSYD)
Entity Type:Individual
Prefix:
First Name:TOBIAS
Middle Name:D
Last Name:KAEMMERER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2901 W KINNICKINNIC RIVER PKWY STE 403
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3660
Practice Address - Country:US
Practice Address - Phone:414-385-8771
Practice Address - Fax:414-385-2399
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-009517103T00000X
WI3497103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100070118Medicaid