Healthcare Provider Details

I. General information

NPI: 1003600271
Provider Name (Legal Business Name): PAONESSAS' SOBER LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2025
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 POMO RD
CLEARLAKE CA
95422-8004
US

IV. Provider business mailing address

3549 CIWA ST
CLEARLAKE CA
95422-8236
US

V. Phone/Fax

Practice location:
  • Phone: 707-245-7613
  • Fax:
Mailing address:
  • Phone: 707-245-7613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SHAWN PAONESSA
Title or Position: PARTNER
Credential: SUDCC II
Phone: 707-245-7613