Provider Demographics
NPI:1326330291
Name:KACZMAREK, TERI L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TERI
Middle Name:L
Last Name:KACZMAREK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 WISCONSIN AMERICAN DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-2999
Mailing Address - Country:US
Mailing Address - Phone:920-907-7000
Mailing Address - Fax:
Practice Address - Street 1:210 WISCONSIN AMERICAN DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-2999
Practice Address - Country:US
Practice Address - Phone:920-907-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2066-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist