Healthcare Provider Details

I. General information

NPI: 1891483533
Provider Name (Legal Business Name): QUINTIN EDWARD INGRAM LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 S RIVER ST
AURORA IL
60506-5185
US

IV. Provider business mailing address

70 S RIVER ST
AURORA IL
60506-5185
US

V. Phone/Fax

Practice location:
  • Phone: 630-779-2045
  • Fax:
Mailing address:
  • Phone: 630-844-2662
  • Fax: 630-844-3084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: