Healthcare Provider Details

I. General information

NPI: 1124751441
Provider Name (Legal Business Name): BLAINE KEATON DAIMARU LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 E 7800 S STE 210
SANDY UT
84094-7228
US

IV. Provider business mailing address

1218 E 7800 S STE 210
SANDY UT
84094-7228
US

V. Phone/Fax

Practice location:
  • Phone: 480-687-3435
  • Fax:
Mailing address:
  • Phone: 480-687-3435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-23132
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11302959-3501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5471460
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: