Healthcare Provider Details

I. General information

NPI: 1912507021
Provider Name (Legal Business Name): LUCID LANE PROVIDERS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 01/29/2021
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3251 PLACE DU JARDIN OPTIONAL
SAN JOSE CA
95148-9514
US

IV. Provider business mailing address

3251 PLACE DU JARDIN
SAN JOSE CA
95148-3851
US

V. Phone/Fax

Practice location:
  • Phone: 630-589-2730
  • Fax:
Mailing address:
  • Phone: 630-589-2730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MUBEENA SIDDIQUI
Title or Position: DIRECTOR OF RCM AND COMPLIANCE
Credential: MA
Phone: 630-589-2730