Basic Information
Provider Information | |||||||||
NPI: | 1043516966 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ADAMS | ||||||||
FirstName: | DEBBIE | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | SSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 55 S. 500 E. | ||||||||
Address2: |   | ||||||||
City: | HEBER | ||||||||
State: | UT | ||||||||
PostalCode: | 84032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4356543003 | ||||||||
FaxNumber: | 8016540309 | ||||||||
Practice Location | |||||||||
Address1: | 5965 S 900 E | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841211720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8012637100 | ||||||||
FaxNumber: | 8012736363 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/10/2011 | ||||||||
LastUpdateDate: | 06/29/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 130294-3503 | UT | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 101YM0800X | 130294-3503 | UT | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 1043516966 | 05 | UT |   | MEDICAID |