Provider Demographics
NPI:1346709029
Name:LECLERC, STACEY (BS, LCDP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:LECLERC
Suffix:
Gender:F
Credentials:BS, LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 N MAIN ST UNIT 4
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:528 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5757
Practice Address - Country:US
Practice Address - Phone:401-276-4020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00784101YA0400X
RIMHC01402101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty