Provider Demographics
NPI:1780837047
Name:SCHWEBACH, ADAM J (PHD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:J
Last Name:SCHWEBACH
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:PO BOX 95970
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0970
Mailing Address - Country:US
Mailing Address - Phone:800-658-8556
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:1477 N 2000 W
Practice Address - Street 2:SUITE E
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8638
Practice Address - Country:US
Practice Address - Phone:801-614-5866
Practice Address - Fax:801-825-1162
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-30
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT360871-2501103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1780837047Medicaid
UTU000074643Medicare PIN