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General NPI Number Information
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NPI Number | 1972478931
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Entity Type | Organization
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Legal Business Name | EASTERN FAMILY TRAUMA TREATMENT CENTER, LLC
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Dates
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Enumeration Date | 10/09/2025
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 2640 HOLLYWOOD BLVD STE 118
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City | HOLLYWOOD
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State | FL
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Zip | 33020-4830
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Country | US
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Telephone | 954-778-3277
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Fax |
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Provider Business Mailing Address
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Address Line | 812 S RIVERSIDE DR
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City | POMPANO BEACH
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State | FL
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Zip | 33062-6200
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Country | US
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Telephone | 954-253-2720
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Fax |
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Authorized Official
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Title or Position | OWNER, CLINICAL DIRECTOR
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Name | KATIA TIKHONRAVOVA
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Credential | LMFT
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Telephone | 954-253-2720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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