Healthcare Provider Details

I. General information

NPI: 1083500425
Provider Name (Legal Business Name): MICHAEL J KELLER ED.D., LEP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 BLUMONT ST
LAGUNA BEACH CA
92651-2356
US

IV. Provider business mailing address

550 BLUMONT ST
LAGUNA BEACH CA
92651-2356
US

V. Phone/Fax

Practice location:
  • Phone: 949-497-7700
  • Fax:
Mailing address:
  • Phone: 949-497-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3011
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: