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General NPI Number Information
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NPI Number | 1679389217
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Entity Type | Organization
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Legal Business Name | BODYMIND INTEGRATED COUNSELING CENTER
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Dates
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Enumeration Date | 12/09/2024
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Last Update Date | 09/23/2025
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Provider Practice Location Address
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Address Line | 15000 POTOMAC TOWN PL # 184
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City | WOODBRIDGE
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State | VA
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Zip | 22191-6586
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Country | US
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Telephone | 571-327-0890
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Fax |
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Provider Business Mailing Address
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Address Line | 15000 POTOMAC TOWN PL # 184
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City | WOODBRIDGE
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State | VA
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Zip | 22191-6586
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CONNOR KEUNTJE
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Credential | LPC, LCPC
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Telephone | 571-327-0890
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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