Provider Demographics
NPI:1376660860
Name:KAMMERMAN, MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:KAMMERMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2564 STATE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1662
Mailing Address - Country:US
Mailing Address - Phone:760-729-4931
Mailing Address - Fax:760-729-3846
Practice Address - Street 1:2564 STATE ST
Practice Address - Street 2:SUITE B
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1662
Practice Address - Country:US
Practice Address - Phone:760-729-4931
Practice Address - Fax:760-729-3846
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5114103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical