Provider Demographics
NPI:1447519913
Name:MK NEW LIFE
Entity type:Organization
Organization Name:MK NEW LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MASAMI
Authorized Official - Middle Name:TANAKA
Authorized Official - Last Name:KOLBENSCHLAG
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:941-275-7966
Mailing Address - Street 1:3800 S TAMIAMI TRL
Mailing Address - Street 2:PARADISE PLAZA SUITE 305
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-6908
Mailing Address - Country:US
Mailing Address - Phone:941-275-7966
Mailing Address - Fax:941-429-7705
Practice Address - Street 1:3800 S TAMIAMI TRL
Practice Address - Street 2:PARADISE PLAZA SUITE 305
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-6908
Practice Address - Country:US
Practice Address - Phone:941-275-7966
Practice Address - Fax:941-429-7705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9277101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ148MOtherBCBSFL
FL60054OtherAETNA
FL60054OtherAETNA