Provider Demographics
NPI:1679389217
Name:BODYMIND INTEGRATED COUNSELING CENTER
Entity type:Organization
Organization Name:BODYMIND INTEGRATED COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONNOR
Authorized Official - Middle Name:
Authorized Official - Last Name:KEUNTJE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LCPC
Authorized Official - Phone:571-327-0890
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:
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:571-327-0890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-09
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health