Provider Demographics
NPI:1356460414
Name:BOTHA, GIDEON PETRUS (LPC, LMFT)
Entity Type:Individual
Prefix:MR
First Name:GIDEON
Middle Name:PETRUS
Last Name:BOTHA
Suffix:
Gender:M
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 BRITTANY COLONY DR
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6246
Mailing Address - Country:US
Mailing Address - Phone:281-316-0548
Mailing Address - Fax:281-316-0548
Practice Address - Street 1:2160 BRITTANY COLONY DR
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6246
Practice Address - Country:US
Practice Address - Phone:281-316-0548
Practice Address - Fax:281-316-0548
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200848106H00000X
TX61340101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist