Healthcare Provider Details

I. General information

NPI: 1144214792
Provider Name (Legal Business Name): THEODORE PETER MASINO II PSY. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 JOHN SIMS PKWY E
NICEVILLE FL
32578-2027
US

IV. Provider business mailing address

507 JOHN SIMS PKWY E
NICEVILLE FL
32578-2027
US

V. Phone/Fax

Practice location:
  • Phone: 850-424-5210
  • Fax: 850-424-3220
Mailing address:
  • Phone: 850-424-5210
  • Fax: 850-424-3220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY6920
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: