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General NPI Number Information
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NPI Number | 1982832614
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Entity Type | Organization
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Legal Business Name | MASINO THERAPY SERVICES, LLC
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Dates
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Enumeration Date | 07/01/2009
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Last Update Date | 03/02/2012
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Provider Practice Location Address
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Address Line | 1008 AIRPORT RD
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City | DESTIN
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State | FL
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Zip | 32541-2823
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Country | US
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Telephone | 850-424-5210
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Fax | 850-424-3220
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Provider Business Mailing Address
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Address Line | 1008 AIRPORT RD SUITE D
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City | DESTIN
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State | FL
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Zip | 32541-2823
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Country | US
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Telephone | 850-424-5210
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Fax | 850-424-3220
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. THEODORE PETER MASINO II
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Credential | PSY.D.
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Telephone | 850-797-6060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | PY6559
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | PY6920
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License Number State | FL
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