Healthcare Provider Details

I. General information

NPI: 1669039178
Provider Name (Legal Business Name): BLUE HERON NEUROFEEDBACK AND COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 WHITE MOUNTAIN HWY
CONWAY NH
03818-4206
US

IV. Provider business mailing address

111 SARANAC ST STE 140
LITTLETON NH
03561-4089
US

V. Phone/Fax

Practice location:
  • Phone: 603-356-6400
  • Fax: 603-413-4666
Mailing address:
  • Phone: 603-356-6400
  • Fax: 603-413-4666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STACIE L LECLERC
Title or Position: OWNER
Credential: LCMHC, MLADC
Phone: 603-356-6400