Healthcare Provider Details

I. General information

NPI: 1396777454
Provider Name (Legal Business Name): EDWARD D SOREL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N CAYGUA STREET
ITHACA NY
14850
US

IV. Provider business mailing address

110 N CAYGUA STREET
ITHACA NY
14850
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-1038
  • Fax: 607-256-8363
Mailing address:
  • Phone: 607-273-1038
  • Fax: 607-256-8363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number06772
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number06772
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: