Provider Demographics
NPI:1225221591
Name:MAKGABENYANA, BOITUMELO GERTRUDE (MA CLINICAL MENTAL)
Entity Type:Individual
Prefix:MRS
First Name:BOITUMELO
Middle Name:GERTRUDE
Last Name:MAKGABENYANA
Suffix:
Gender:F
Credentials:MA CLINICAL MENTAL
Other - Prefix:MS
Other - First Name:BOITUMELO
Other - Middle Name:GERTRUDE
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA GENERAL PSYCH
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201
Mailing Address - Country:US
Mailing Address - Phone:605-886-0123
Mailing Address - Fax:605-886-5447
Practice Address - Street 1:123 19TH ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201
Practice Address - Country:US
Practice Address - Phone:605-886-0123
Practice Address - Fax:605-886-5447
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5200010Medicaid