Provider Demographics
NPI:1750179115
Name:BELTON, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:BELTON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4430 N HOLLAND SYLVANIA RD APT 4105
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-3562
Mailing Address - Country:US
Mailing Address - Phone:313-244-7797
Mailing Address - Fax:
Practice Address - Street 1:3829 WOODLEY RD STE 6
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1174
Practice Address - Country:US
Practice Address - Phone:313-244-7977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH106E00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty