Provider Demographics
NPI:1962818195
Name:KERETSES, ELENA (SCAT, ATC, EMTB)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:KERETSES
Suffix:
Gender:F
Credentials:SCAT, ATC, EMTB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 GRAYSCROFT DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6678
Mailing Address - Country:US
Mailing Address - Phone:704-989-6039
Mailing Address - Fax:
Practice Address - Street 1:1700 GRAYSCROFT DR
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6678
Practice Address - Country:US
Practice Address - Phone:704-989-6039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC0349782255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer