Provider Demographics
NPI:1912507021
Name:LUCID LANE PROVIDERS, P.C.
Entity Type:Organization
Organization Name:LUCID LANE PROVIDERS, P.C.
Other - Org Name:LUCID LANE PROVIDERS, P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF RCM AND COMPLIANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MUBEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:630-589-2730
Mailing Address - Street 1:3251 PLACE DU JARDIN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-3851
Mailing Address - Country:US
Mailing Address - Phone:630-589-2730
Mailing Address - Fax:
Practice Address - Street 1:3251 PLACE DU JARDIN
Practice Address - Street 2:OPTIONAL
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-9514
Practice Address - Country:US
Practice Address - Phone:630-589-2730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-28
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty