Provider Demographics
NPI:1124092911
Name:LEGACY CLINICAL CONSULTANTS, LLC
Entity type:Organization
Organization Name:LEGACY CLINICAL CONSULTANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:VANMETER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:877-443-7030
Mailing Address - Street 1:13300 S ROUTE 59
Mailing Address - Street 2:SUITE B-7
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-9847
Mailing Address - Country:US
Mailing Address - Phone:815-577-3666
Mailing Address - Fax:815-577-2785
Practice Address - Street 1:3033 OGDEN AVE STE 200
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1976
Practice Address - Country:US
Practice Address - Phone:877-443-7030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X, 103TF0000X, 104100000X, 106H00000X, 101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 103T00000X, 103TA0700X, 103TB0200X, 103G00000X
IL149.0080751041C0700X
IL071.006312103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9932120OtherBLUE CROSS BLUE SHIELD
IL9932120OtherBLUE CROSS BLUE SHIELD
ILK10876Medicare ID - Type UnspecifiedMEMBER NUMBER