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General NPI Number Information
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NPI Number | 1124751441
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Entity Type | Individual
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Provider Name | BLAINE KEATON DAIMARU LCSW
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Gender | Male
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Dates
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Enumeration Date | 07/05/2022
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Last Update Date | 07/05/2022
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Provider Practice Location Address
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Address Line | 11260 S RIVER HEIGHTS DR
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City | SOUTH JORDAN
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State | UT
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Zip | 84095-5119
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Country | US
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Telephone | 801-298-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 11260 S RIVER HEIGHTS DR
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City | SOUTH JORDAN
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State | UT
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Zip | 84095-5119
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Country | US
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Telephone | 801-298-2000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 11302959-3501
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License Number State | UT
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