Healthcare Provider Details

I. General information

NPI: 1972478931
Provider Name (Legal Business Name): EASTERN FAMILY TRAUMA TREATMENT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 HOLLYWOOD BLVD STE 118
HOLLYWOOD FL
33020-4830
US

IV. Provider business mailing address

812 S RIVERSIDE DR
POMPANO BEACH FL
33062-6200
US

V. Phone/Fax

Practice location:
  • Phone: 954-778-3277
  • Fax:
Mailing address:
  • Phone: 954-253-2720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATIA TIKHONRAVOVA
Title or Position: OWNER, CLINICAL DIRECTOR
Credential: LMFT
Phone: 954-253-2720