Provider Demographics
NPI:1740159805
Name:MUSGROW, QUINTON
Entity type:Individual
Prefix:
First Name:QUINTON
Middle Name:
Last Name:MUSGROW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 E IRELAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2845
Mailing Address - Country:US
Mailing Address - Phone:574-387-4313
Mailing Address - Fax:574-204-2868
Practice Address - Street 1:1045 12TH AVE
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-1474
Practice Address - Country:US
Practice Address - Phone:574-387-4313
Practice Address - Fax:574-204-2868
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-05
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-25-487351106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician