Healthcare Provider Details

I. General information

NPI: 1093947400
Provider Name (Legal Business Name): CONNOR KEUNTJE LPC, LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15000 POTOMAC TOWN PL # 184
WOODBRIDGE VA
22191-6586
US

IV. Provider business mailing address

15000 POTOMAC TOWN PL # 184
WOODBRIDGE VA
22191-6586
US

V. Phone/Fax

Practice location:
  • Phone: 703-493-0650
  • Fax:
Mailing address:
  • Phone: 703-493-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701009042
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC14465
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC12515
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: