# LUCID LANE PROVIDERS, P.C.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Lucid Lane Providers, P.C.
- **Organization subpart:** No

## Provider details

- **NPI number:** 1912507021
- **Authorized official:** MRS. MUBEENA SIDDIQUI MA (DIRECTOR OF RCM AND COMPLIANCE)
- **Authorized official phone:** (630) 589-2730

## Contact information

- **Practice address:** 3251 PLACE DU JARDIN, OPTIONAL, SAN JOSE, CA 95148-9514
- **Practice address phone:** (630) 589-2730
- **Mailing address:** 3251 PLACE DU JARDIN, SAN JOSE, CA 95148-3851
- **Mailing address phone:** (630) 589-2730

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 101YM0800X | Mental Health Counselor | — | NULL | Yes |
| 101YM0800X | Mental Health Counselor | — | — | Yes |
| 101YP2500X | Professional Counselor | — | NULL | — |
| 101YP2500X | Professional Counselor | — | — | — |
| 103TC0700X | Clinical Psychologist | — | NULL | — |
| 103TC0700X | Clinical Psychologist | — | — | — |
| 103TP2701X | Group Psychotherapy Psychologist | — | NULL | — |
| 103TP2701X | Group Psychotherapy Psychologist | — | — | — |
| 1041C0700X | Clinical Social Worker | — | NULL | — |
| 1041C0700X | Clinical Social Worker | — | — | — |
| 207R00000X | Internal Medicine Physician | — | NULL | — |
| 207R00000X | Internal Medicine Physician | — | — | — |
| 2083X0100X | Occupational Medicine Physician | — | NULL | — |
| 2083X0100X | Occupational Medicine Physician | — | — | — |
| 2084P0800X | Psychiatry Physician | — | NULL | — |
| 2084P0800X | Psychiatry Physician | — | — | — |

## Other

- **Enumeration date:** 10/28/2020
- **Last updated:** 01/29/2021