Provider Demographics
NPI:1093947400
Name:KEUNTJE, CONNOR (LPC, LCPC)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:KEUNTJE
Suffix:
Gender:M
Credentials:LPC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:OCCOQUAN
Mailing Address - State:VA
Mailing Address - Zip Code:22125-0435
Mailing Address - Country:US
Mailing Address - Phone:703-493-0650
Mailing Address - Fax:
Practice Address - Street 1:12701 MARBLESTONE DR STE 350
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-8327
Practice Address - Country:US
Practice Address - Phone:703-493-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC12515101YP2500X
DCPRC14465101YP2500X
VA0701009042101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional