MEDICARE: EASTERN FAMILY TRAUMA TREATMENT CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
2	261QM1300X	Multi-Specialty Clinic/Center
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
4	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1972478931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTERN FAMILY TRAUMA TREATMENT CENTER, LLC

Provider Business Mailing Address
First Line	:	812 S RIVERSIDE DR
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062-6200
Country	:	US
Telephone Number	:	954-253-2720
Fax Number	:

Provider Business Practice Location Address
First Line	:	2640 HOLLYWOOD BLVD STE 118
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-4830
Country	:	US
Telephone Number	:	954-778-3277
Fax Number	:

Authorized Official
Title or Position	:	OWNER, CLINICAL DIRECTOR
Name	:	KATIA TIKHONRAVOVA
Credential	:	LMFT
Telephone Number	:	954-253-2720

Provider Enumeration Date	:	10/09/2025
Last Update Date	:	12/03/2025

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