Provider Demographics
NPI:1669039178
Name:BLUE HERON NEUROFEEDBACK AND COUNSELING
Entity type:Organization
Organization Name:BLUE HERON NEUROFEEDBACK AND COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LECLERC
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC, MLADC
Authorized Official - Phone:603-356-6400
Mailing Address - Street 1:111 SARANAC ST STE 140
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:NH
Mailing Address - Zip Code:03561-4089
Mailing Address - Country:US
Mailing Address - Phone:603-356-6400
Mailing Address - Fax:603-413-4666
Practice Address - Street 1:379 WHITE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-4206
Practice Address - Country:US
Practice Address - Phone:603-356-6400
Practice Address - Fax:603-413-4666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-21
Last Update Date:2025-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3138509Medicaid
NH3147125Medicaid
NH3118551Medicaid
NH3149511Medicaid
NH3148512Medicaid
NH3138507Medicaid
NH3138508Medicaid
NH3147950Medicaid