Provider Demographics
NPI:1467636167
Name:LECLERC, STACIE L
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:L
Last Name:LECLERC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 TOWN HALL RD
Mailing Address - Street 2:
Mailing Address - City:INTERVALE
Mailing Address - State:NH
Mailing Address - Zip Code:03845-6108
Mailing Address - Country:US
Mailing Address - Phone:603-356-6400
Mailing Address - Fax:603-447-8893
Practice Address - Street 1:3277 WHITE MOUNTAIN HIGHWAY
Practice Address - Street 2:
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860
Practice Address - Country:US
Practice Address - Phone:603-356-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0960101YA0400X
NH739101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3111019Medicaid