Provider Demographics
NPI:1639476807
Name:KELLER, MEGAN RENEE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:RENEE
Last Name:KELLER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 PORTOLA PKWY
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-2200
Mailing Address - Country:US
Mailing Address - Phone:949-648-3698
Mailing Address - Fax:
Practice Address - Street 1:513 E 1ST ST
Practice Address - Street 2:STE C
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3348
Practice Address - Country:US
Practice Address - Phone:949-648-3698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMFT 66151106H00000X
CAMFC53235106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist