MEDICARE: DR. MICHAEL J KELLER ED.D., LEP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	3011	CA

General Provider Information

NPI Number	:	1083500425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL J KELLER ED.D., LEP

Provider Business Mailing Address
First Line	:	550 BLUMONT ST
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-2356
Country	:	US
Telephone Number	:	949-497-7700
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 BLUMONT ST
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-2356
Country	:	US
Telephone Number	:	949-497-7700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2025
Last Update Date	:	12/02/2025

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