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General NPI Number Information
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NPI Number | 1669039178
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Entity Type | Organization
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Legal Business Name | BLUE HERON NEUROFEEDBACK AND COUNSELING
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Dates
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Enumeration Date | 05/21/2019
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Last Update Date | 11/11/2025
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Provider Practice Location Address
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Address Line | 379 WHITE MOUNTAIN HWY
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City | CONWAY
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State | NH
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Zip | 03818-4206
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Country | US
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Telephone | 603-356-6400
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Fax | 603-413-4666
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Provider Business Mailing Address
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Address Line | 111 SARANAC ST STE 140
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City | LITTLETON
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State | NH
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Zip | 03561-4089
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Country | US
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Telephone | 603-356-6400
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Fax | 603-413-4666
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Authorized Official
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Title or Position | OWNER
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Name | STACIE L LECLERC
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Credential | LCMHC, MLADC
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Telephone | 603-356-6400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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