Healthcare Provider Details

I. General information

NPI: 1912868902
Provider Name (Legal Business Name): TI'IA MCKENZIE-DANTITIES FRIISVALL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2025
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 FULTON ST W APT 319
GRAND RAPIDS MI
49504-6399
US

IV. Provider business mailing address

616 FULTON ST W APT 319
GRAND RAPIDS MI
49504-6399
US

V. Phone/Fax

Practice location:
  • Phone: 906-201-7773
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501016458
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: