Healthcare Provider Details

I. General information

NPI: 1467636167
Provider Name (Legal Business Name): STACIE L LECLERC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3277 WHITE MOUNTAIN HIGHWAY
NORTH CONWAY NH
03860
US

IV. Provider business mailing address

286 TOWN HALL RD
INTERVALE NH
03845-6108
US

V. Phone/Fax

Practice location:
  • Phone: 603-356-6400
  • Fax:
Mailing address:
  • Phone: 603-356-6400
  • Fax: 603-447-8893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0960
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number739
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: