Healthcare Provider Details

I. General information

NPI: 1114449949
Provider Name (Legal Business Name): TOBIAS D KAEMMERER PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 W KINNICKINNIC RIVER PKWY STE 403
MILWAUKEE WI
53215-3660
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-385-8771
  • Fax: 414-385-2399
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071-009517
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3497
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: